Even before the Cardiology Clinic at the Cincinnati VA instituted Advanced Clinic Access, they knew they had a problem that had to be dealt with, "to take proper care of our patients," according to Dr. Seymour Maze, chief of the section. Waiting times for all appointment types were running as long as 70 to 80 days in May 2000. They knew that, in order to take proper care of patients who truly needed a sub-specialist level of care, they would have to shape the demand for patients currently being referred to cardiology who could better be cared for in primary care.
Work Down the Backlog
To address the urgent problem they were experiencing at the beginning of their improvement efforts, clinic staff put a number of solutions in place: they divided the follow-up appointments from the new consults and started a clinic for new patients only. This enabled them to develop a tracking mechanism to better identify the bottlenecks in the scheduling process. To work down the backlog, they expanded the number of patients that could be scheduled for each provider.
The benefits of these changes were soon obvious. Even before seeing the waiting times data, the clinic staff soon realized they had easier and less congested clinics, less crowded waiting rooms, and greater ease getting patients into the clinic, Maze said. And, although they had not done formal measurements, patient satisfaction was up. The waiting times data showed that they were on the right track. Waiting times data for June, July, and August in 2000 showed marked improvements over the May data (see Figure 1).
Streamline the Consult Process
The core strategy for maintaining the initial improvements was two-pronged: consult triage and clinic discharge. Consult triage is now done as part of the consult request process. The computer form was modified "so that when clinicians entered the cardiology consult, they got a sublisting of our most frequent diagnoses—for example, chest pain or atrial fibrillation or valve disease—and once they clicked on that term, they got . . . a menu of things to consider before entering the consult," said Curtis Chaney, the clinic’s Congestive Heart Failure (CHF) case manager. The menu consists of tests for the referring provider to consider before requesting the consult. "That way, we don’t see a patient in clinic and have to order tests that could have been accomplished beforehand and tie up another appointment slot when he returns," Chaney said.
Streamlining consults can be a bit tricky, especially if primary care providers view the process as restrictive. But the cardiology clinic staff has been attuned to this, trying to make the process educational for primary care providers while remaining open and freely available "to any physician who needs us for whatever reason," Maze emphasized. Failure to check a certain box, for example, would not be cause for the consult to be rejected. Further, the consult form was kept deliberately flexible, using relatively large amounts of free text so that primary care providers could enter problems in their own words.
Once the consult request has been completed, Curtis performs "consult triage," directing patients into specific clinics as indicated. Consult triage allows some 15 to 20 percent of problems to be answered without the patient having to be seen in the cardiology clinic. Two examples of patient problems that can be assessed by information available in the chart rather than requiring a consult visit include medication that is restricted to cardiology prescribing and preoperative consultation.
The redesign of the consult process ensures that only patients who actually need to be seen by a cardiologist come to the clinic. Maze noted that, rather than creating a situation where patients do not receive care, this system results in patients being given better care, especially if it reduces unnecessary testing or unnecessary clinic visits.
Eliminate Unnecessary Follow-Up Visits
The clinic has also made a concerted effort to discharge patients who don’t need to be followed by a cardiologist. These patients can instead be managed well by primary care providers. How was this accomplished? First, in their assessment of patients waiting for appointments, the clinic staff noted that there was a group of stable patients, with no hospital admissions or medication changes, who had been returning to clinic every six months for years without any cardiology intervention. Using a locally developed guideline, the staff ensured that these patients had a primary care provider and then cleared them for discharge from the clinic. At the same time that the primary care provider was notified, patients received a letter telling them they did not require the routine attention of a cardiologist but were welcome to come back at any time they or their primary care provider felt they needed to.
Monitoring the Results
The efforts to redesign the consult intake and discharge processes paid off. In November 2002, the average waiting time to the next available appointment dropped below 20 days to 18.3 days (Figure 1).*
Figure 1 Average Waiting Time to the Next Available Appointment
The reduction in average waiting time to the next available appointment, as shown in Figure 1, was accomplished while the number of consults remained relatively stable (Figure 2), suggesting that that the improvements in access are most likely not attributable to reductions in demand.
Figure 2 Total and New Outpatient Consults
The national waiting times data is monitored closely to identify any variation in clinic performance. Changes in waiting times from month to month can be due to the natural variation in the system or to special causes such as clerical errors in entering clinic appointments. A closer review of the actual waiting times for appointments in August, October, and December 2002 (which were actually within the 30- to 45-day range) revealed that scheduling errors contributed to the reported sharp rises in waiting times. Weekly checks of the waiting times at the clinic level (before the data is submitted to the national database) can proactively correct these errors, ensuring that the reported data accurately reflect the real waiting time for patients. Figure 3 is an example of a weekly monitoring report that helps to identify unusual patterns in the data so that any errors can be corrected if necessary prior to data submission. Denise Strimple explained that she conducts weekly tallies of waiting times for each clinic, pulling up all profiles and hand-counting them "clinic slot by clinic slot."
Figure 3 Sample Weekly Check of Waiting Times to Third and First Next Available Appointment
Adjusting and Fine-Tuning
With the innovations in place and with close monitoring of the waiting times data, the clinic was able to adjust to a sudden decrease in number of providers. Because one staff member left on short notice (see May 2002 in Figure 1), the clinic didn’t have much time to plan, but they coped by having the CHF case manager increase the number of patients he was managing and having other attendings absorb the remainder. By June 2002, the waiting time for appointments had returned to its normal level. As Strimple points out, "We did find that no matter how much you tweak a clinic, you can tweak it again." At present the clinic staff consists of three attendings, 11 rotating fellows, a program specialist, a CHF case manager, and a clinic clerk.
One of the most positive outcomes of this clinic’s Advanced Clinic Access process has been better control of clinics by the physicians, particularly by the fellows. Now patients are scheduled more appropriately and discharged proactively. The physicians have learned how to manage their own clinic populations such that patients get better and faster care. Still, "it’s an ongoing process," Denise Strimple says, "that needs attention week by week, month by month, in an ongoing review."
* Data source: VHA National Clinic Appointment Wait Times database
