Before Advanced Clinic Access (ACA) came to the VA Urology Clinic in Fargo, North Dakota, patients and providers were frustrated by the long waits and clogged appointment schedules that were typical of the system. Patients waited an average of 90 days to get an appointment to see the urologist. Urology clinics were booked solid every day, with several slots double-booked. Dr. Terry Duffy, the urologist at the Fargo clinic, describes a typical day: "I had 30 slots, and all 30 were booked, with four or five over-books. If there was an emergency in the middle of the day, I’d have to go to the operating room for an hour, and when I got back, I had to take care of the six patients who were scheduled during the hour I was gone, in addition to everybody else. My day started off bad and only got worse."
The promise of better work days was a major motivator for Duffy to undertake the changes known collectively as "Advanced Clinic Access" — second only to the promise of being able to provide better care for his patients. "These guys all have urology problems," Duffy says of his patients, "and they were frustrated. In their mind, it was an emergency. And whether it was or was not, they didn’t want to wait three months to find out. They would often arrive angry because they had been waiting so long." Not only that, but the Fargo clinic, the only VA facility in North Dakota, is located on the eastern border of a state that takes eight hours to drive across. "I had patients do the 400-mile drive in a snowstorm in January," Duffy says. "This is a poor state, farmers are going out of business, and these guys don’t have private health insurance. This is the only health care access they have."
Now both Duffy and his patients are seeing first-hand the results applying the principles of "Advanced Clinic Access." Within three months, the waiting time for appointments dropped from 90 days to same-day access.*
Working Down the Backlog
Attending Advanced Clinic Access training, Duffy realized that the first thing he had to do was work down the backlog. "They explained that the backlog had remained 90 days for years," he says. "It wasn’t getting any worse, but I was carrying it forward from year to year. If I could get rid of that backlog, I could keep up." To work down the backlog, he temporarily added ten slots to the day, booking two patients for 15-minute slots every morning. "I knew that it was going to be miserable," he says, "but I just decided to put my head down and do it." After two months, the backlog was gone.
Discharging Patients to Primary Care
The next change, as Duffy puts it, was "a change in my attitude." "Traditionally, especially in the VA, you never discharge a patient," he explains. "The only way a patient gets out of the urology clinic is to die or move away." Duffy admits he shared that mindset, routinely bringing his patients back for checkups every three or six months—thereby clogging his own schedule. "I was responsible for filling up 60 to 70 percent of my future appointments," he explains. "I was my own worst enemy."
The change? Simple: When an internist referred a patient with a urology problem, Duffy would see the patient, diagnose the problem, treat it, and discharge the patient. No matter what the urology problem was, once the patient was stable and/or/or treated for the problem, he was discharged back to primary care. How hard was it to make the change? According to Duffy, not hard at all. Instead of seeing 30 patients and bringing all but two of them back for follow-up appointments, he started doing the exact reverse: scheduling only two, on the average, for follow-up. "I’d tell the patient, ‘We’re making changes, and this is the best thing for you. If you want to see me in the future, number one, you won’t have to get a referral; just call the urology clerk and say you want to see me. And number two, I’ll be able to see you the same day.’" And, with a schedule freed of a backlog and a more judicious use of follow up appointments, i.e., reduced "front log," Duffy was able to make good on that promise.
Using Alternatives to Face-to-Face Visits
Duffy also realized that even patients who did need follow-up care did not necessarily need to come in for an office visit. Most of his patients were men with either enlarged prostates (BPH) or erectile dysfunction (ED). Traditionally, patients in these groups got a trial of a medication, returning in one month for follow up. "A lot of these guys were driving 200, 300 miles to say, ‘That’s a great drug. It really works and no, I’m not having any side effects,’" Duffy explains. "They’d drive 200 miles for a 60-second meeting."
Instead of bringing these patients back for an office visit, Duffy began sending email reminders to himself to check up with them by phone. Now, when he starts a patient on a trial of a drug, he uses the VA’s scheduling system (VISTA) to send himself an email reminder in 30 days. And when he arrives at the office in the morning, before seeing patients, he opens his email reminders for that day and phones the patients to follow up on the 30-day trial. "The patients love it," he says. "It saves them a trip, and they feel like they’re getting great service because their doctor is calling them at home. And it decreases my future demand for appointments."
Using Service Agreements with Primary Care
Duffy also began working closely with internal medicine to reduce the number of urology consults and to streamline the process for those patients who did need consults. Typically, five problems account for almost all urology consults: hematuria, elevated PSA, erectile dysfunction, urinary tract infection, and scrotal mass. Before the change, a patient would be referred to Duffy for one of these conditions, only to find that certain procedures needed to be done before he could be treated—in effect, a wasted visit. Using the computerized medical record system (CPRS),; Duffy created five urology screens, one for each condition. Duffy worked with the computer technicians to expand the use of order sets so that the computer shows the necessary orders for specific conditions, and then automatically makes those orders. Now, when the primary care provider wants to refer a patient to urology—for example, for urinary tract infection—he or she selects the appropriate condition and a screen pops up saying, "Prior to Urology Appointment, please obtain: 1.Urinalysis and Urine Culture and 2. Renal Ultrasound, and the computer automatically orders the two required tests. And when that patient arrives in his office, Duffy has the required test results in hand. "Instead of sending the patient back for an ultrasound, I can say, ‘The ultrasound of your kidney was fine. We now need to look in your bladder.’ Within five minutes, I can complete the entire workup."
After Duffy had the five computer screens built, he met with the primary care providers to explain the new process. "The first thing I said to them was, ‘Let’s communicate more. Just call me. I’m happy to answer questions because it makes my life easier and it helps you.’" Duffy continues to have regular meetings with the primary care providers to check in on how the process is going.
Working Out New Team Roles
Making the changes to move to Advanced Clinic Access entailed new roles for the members of the urology team—not an easy adjustment in all cases. Clerks like using the new system that has just two choices of appointment type: "appointment slots" and "procedure slots." They also like being able to schedule any patient who requests an appointment, without requiring a referral from primary care ("They like not having to play God," as Duffy puts it). Nurses, on the other hand, at first resisted taking on new responsibilities that they perceived as being "extra work." "Now, if I decide a patient needs a prostate biopsy, I give it to my nurse to handle," Duffy says. Instead of just rooming patients, the nurse works with the patient to explain preparation for the procedure, including medication regimen, and calls the scheduling clerk to set it up—changes that free up the specialist to do special work. Instead of seeing this as extra work, nurses have come to recognize and enjoy increased customer satisfaction and personal satisfaction in being more involved in the care process.
Seeing Results and Spreading the Changes
Within three months of implementing these changes, Dr. Duffy went from having a full schedule every day to have five or six open slots per day. "Now, a primary care provider will call me and say, ‘I’m really worried about this guy,’ and I can say, ‘Send him upstairs now.’ Patients are getting seen by the specialist in 15 minutes." Duffy can handle surprises like emergency surgery and still stay on time. "Patients love it," he says. "They feel like they’re getting better care: they can get in immediately, they get phone calls at home. The primary care providers love it, too; they can pick up the phone and call me, and I can say, ‘No, you don’t really need a consult for that. Why don’t you try this medication, give it three weeks, and see how he does.’"
What does Dr. Duffy have to say to other specialists in the VA who are considering adopting Advanced Clinic Access? "You have to bite the bullet to get through working down the backlog, but it’s worth it. Yes, it’s possible at your institution; just look at the facts. Yes, my workload has decreased—because I have graduated all of these patients who no longer need to be seen by an urologist. No, you’re not going to work yourself out a job; only the patients who truly need to be seen by me are in the clinic. The last six months of my life have been wonderful."
*This was accomplished with some reductions in the number of new appointments (391 to 132 from March 2001 to February 2002) which may be attributed to a new referral process that cut down on the number of unnecessary consults.