Trimming Health Care’s Excess Waits and Delays

Concern over the large number of Americans with inadequate access to health care has mostly focused on the lack of health insurance. However, having health insurance doesn’t remove all barriers to care. Even insured patients can face weeks-long delays in obtaining non-urgent medical care, such as mammograms or child immunizations. Backlogged medical practices may schedule appointments for routine care so far into the future that some patients never show up – they either forget they had an appointment or decide it’s no longer convenient or important. Those who do appear at the appointed time may face frustratingly long waits for care due to office inefficiencies. The result can be unmet medical needs, unhappy patients, overstressed staffs, and financial strain for the practice as patients go elsewhere or skip care altogether.
         
One solution is “Open Access” (OA), also known as “Advanced Access,” a practice management process that aims to reduce scheduling delays and wait times for patients by improving office procedures.  Developed over the past decade, the guiding principle of Open Access is that the demand for medical care can be managed as efficiently as the demand for airline seats or Starbucks mocha lattes. “There’s no reason why every patient who wants a same-day appointment can’t have one. It may sound impossible but it’s not,” insists Greg Randolph, MD, a pediatrician and Senior Improvement Advisor at the Center for Children’s Healthcare Improvement (CCHI), a University of North Carolina quality improvement group. “That should be our goal.”
         
Randolph has been intrigued by the Open Access idea since he first encountered it in 1999 at the National Forum on Quality Improvement in Health Care, sponsored by the Institute for Healthcare Improvement (IHI). To learn more, he enrolled in an IHI Breakthrough Series Collaborative on Improving Access and Efficiency in Primary Care, held in Boston in 2000. Since then, Randolph has been an active force spreading the Open Access idea across his state, most recently through a project on “Improving Access and Efficiency in Primary Care Practices in North Carolina” sponsored by CCHI, IHI, the National Initiative for Children’s Healthcare Quality (NICHQ),  the North Carolina Division of Medical Assistance (Medicaid), and others.
 
In March 2003, representatives from 27 family medicine, internal medicine, and pediatric practices, mainly in North Carolina, joined a year-long Learning Collaborative to study Open Access principles and apply them to their own offices. Participants met in person or via online conferencing in three two-day Learning Sessions, separated by months-long efforts to test and gradually implement the new techniques in their individual practices. Randolph explains the Open Access process – in simplified and ideal form – this way:
         
Measure supply and demand.  “Sure, demand varies,” says Randolph, “but it varies in predictable ways.” A medical practice can track demand simply by recording every appointment request, fulfilled or not. Patterns will quickly emerge, says Randolph. “Mondays are heavy, Wednesdays are slow. More patients want to come at 9 AM than at 4 PM or vice-versa.” By comparing patient demands to the planned supply of physicians or other needed staff—day by day, hour by hour—shortfalls become obvious.
 
Diminish backlogs.  The transition from long waits to immediate appointments requires practices to whittle down backlogs (i.e., appointments that have been booked into the future and that are already on the schedule).  The most common strategy is to temporarily ramp up capacity with extra hours or staff, but practices may also need to “max-pack” patient visits by anticipating near-term needs and filling them in current encounters. For example, if a child is seen for a cold and is also due for a well child visit the next week, the physician can address both needs in the now earlier appointment, freeing up the following week’s slot for someone else. This intense period will almost certainly involve some pain, admits Randolph, “but there will be a lot of gain.”      
 
Switch over. Once an office has a backlog of less than a week, it’s time to start offering every patient a same-day appointment, says Randolph, an option that all but eliminates no-shows.
 
Stay on top. Patients who do not want same-day appointments can still be scheduled ahead of time, but to maintain Open Access practices must continue tracking demand and supply in order to forecast and plan for variations, such as school breaks, flu season, or staff vacations.
         
Look ahead. Freed from the anxiety and pressure of constant backlogs, practices can contemplate other changes to streamline care processes, boost productivity, and increase staff and patient satisfaction.
         
James Kurz, MD, Medical Director of Chatham Crossing Medical Center, a four-physician internal medicine and pediatrics practice in Chapel Hill that participated in the local Open Access Learning Collaborative, says that one obstacle to Open Access may be physicians’ financial anxiety. “We worry a lot about empty waiting rooms,” he says, “but they’re a good thing when they result from efficiency.” Kurz says that, since his practice implemented Open Access last year, slots that appear empty in the morning almost always fill up later with patients requesting same-day appointments. “And, if not, I can offer the time to a patient to discuss test results or further treatment in person, rather than on the phone.” The result, says Kurz, is that patients feel a stronger bond to their caregivers, “and I sometimes get to go home on time.”
           
As part of CCHI’s effort to encourage the spread of Open Access, Greg Randolph collected data during the Collaborative to quantify how the training affected the 27 practices involved. Though still preliminary, the data show a major impact. On average, the practices slashed their average wait time for appointments from 42 days to 10 days.

 

graph_accessefficiency.jpg 

Source: North Carolina Access and Efficiency Learning Collaborative

 

The average time patients spent in the office, from check-in to check-out, dropped from 70 minutes to 58. Possibly as a result of receiving quicker appointments, the percentage of scheduled patients who didn’t show up dropped from 12 percent to 7 percent with encouraging clinical effects.
 
graph_AEcollaborative_cycletime.jpg 
graph_AEcollaborative_percentnoshow.jpg 
Source: North Carolina Access and
Efficiency Learning Collaborative
 
Mammography screening rates among patients in the 27 practices rose from 67 percent to 83 percent and child preventive care rates, including immunizations and screenings for lead, TB, and anemia, increased from 41 percent to 51 percent. Surprisingly, patient satisfaction only increased by 7 percent, which Randolph says may reflect lagging perception of the improvements.
 
Planning for the next Open Access Learning Collaborative, which is open to primary care practices anywhere in the country, is now underway at CCHI.
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