Advanced-Access Scheduling

Despite their best efforts, or perhaps because of them, most physicians' offices perform well below what's achievable. For instance, the waiting time for both providers and patients can be menacing, staff efficiency is often low, communication and coordination of care are exhausting, and finances are usually strained.

Such a scenario can become the exception, rather than the rule, say the experts, with the application of a relatively new theory. All that is required to reap the rewards, they say, is steadfast faith and staunch commitment.

Mark Murray, MD, the self-proclaimed 'grandfather' of the application of the 'open access' or 'advanced access' theory in healthcare scheduling, began working on the process, along with colleague Catherine Tantau, in the late 1980s. In true advanced access, according to Murray, physicians schedule "today's work today," working with a daily schedule that is 75 percent open for the average family practice.

Murray estimates that 60 general and specialty practices around the United States are applying advanced-access scheduling with remarkable success. The idea - predict demand and hold capacity - works in just about every other industry but has been applied sparingly in healthcare for a number of reasons.

Build it and they will come

For one thing, it takes more than blind faith for most physicians to entirely scrap the way things have always been done. Physicians want information, education, tools, and evidence to support the promised rewards. But Murphy is cautious about looking for a single successful model. "Access improvement is all about principles - supply and demand, flow, capacity. Every organization is a little different. They apply the principles to their own sites. There is not some off-the-shelf product," he explains.

In other words, achieving 'same-day' access and nearly wait-free patient flow may be an individual decision. So ultimately, to demonstrate the rewards and sell others on the concept, someone needs to take the plunge.

David W. Wetherhold, MD, head of internal medicine at Scripps Clinic-Torrey Pines in California was the first to take the leap in his organization, a 300-physician, multi-site practice. And a leap it was indeed. Wetherhold read materials on the concept on a Thursday and by the following Monday he and another colleague had initiated an open-access system that allowed two same-day appointments daily.

Soon, they were able to fill other slots through cancelled appointments and no-shows. Time was also created by implementing standard advanced-access operations suggestions, such as converting sick visits to routine care, which eliminates the need for return visits for physicals and other yearly requirements, and using resources previously dedicated to 'triage' for telephone care, which can often replace return appointments.

In about six weeks, Wetherhold and his colleague each were working with only 40 percent to 50 percent of their schedules booked daily.

Dispelling the fears

Whittling down the backlog of appointments presents one scary aspect of open access. "It was hard putting aside an extra half-hour to hour for this thing that was supposedly going to happen," says Wetherhold. "But once I started doing that and saw the improvements I became a true believer." Not only did patients like it, but also fellow colleagues started taking notice.

Two by two, doctors all around Scripps Clinic began open access to achieve what Wetherhold notes as an average of 70 percent open schedule daily. Today, 95 percent of Scripps Internal Medicine physicians and 30 percent of the specialists use open-access scheduling.

Ultimately, Murray emphasizes, it comes down to changing the way you think and building the system according to what the patients want. There is security in having a schedule booked with 20 patients a day for the next two months. But those in the know insist an unbooked schedule can offer the same security.

"The biggest fear when I started was that I wouldn't have patients," acknowledges Allyn Norman, MD, of Tonawanda Medical Associates in Buffalo, N.Y. "But there has never been a time when I've been able to sit down and do paperwork in the middle of the day." But now, after integrating an advanced-access system, he deals with fewer rescheduled appointments and no-shows, and is actually seeing more patients than ever, he says. And he has more control over his schedule.

"We used to continually run late," he says, "now we stay pretty true to schedule." The family practice office includes Norman, a nurse practitioner, a registered nurse, a medical assistant, and four support staff members. The patient panel nears 6,000, and the staff schedules 44 patient contact hours each week, with evening hours twice weekly. To make it work, everyone had to commit, Norman says, adding that his staff was very flexible, working extra hours to reduce the backlog.

Lack of commitment from the staff is what led to the downfall of open access in one pediatric practice in Leominster, Mass. According to Bruce Man, MD, who initiated the program, when the nine-provider Medical Associates Pediatrics committed to open access about two years ago, only five of the physicians took part. Within five months, open access was discontinued.

"The reason it did not work was not being able to convey to naysayers that it could happen," says Man, who believes the biggest obstacle is selling everyone on the concept. However, after revisiting the experience, many of the practice's physicians now acknowledge that the process had worked. In fact, the changes that advanced access introduced address many of the concerns the practice faced. Man says he looks forward to trying again soon, with the newer models, and hopes to convince the same physicians who so adamantly rejected the idea two years ago.

Little fish in a big pond

Despite Man's failure, a small fish can often change the current in a big pond, as was the case at Scripps. Wetherhold suggests that physicians who want to use advanced access in their own practices shouldn't wait to convince the cynics.

The best advice is to get "a plan together quickly and not [let] it get held up in the bureaucracy characteristic of most institutions," he says. "Start it out on a small group and then let it prove itself from there." Ground rules, though, eventually had to be set at Scripps so that the physicians not using open access were not taking advantage of those who were.

"You just can't do it if you are seeing everyone else's patients," Wetherhold notes. So his department gave open-access doctors full priority with the physician's assistant (PA). Each open-access physician saw no more than two of his colleagues' patients daily; the PA saw the rest. Such a plan had an added benefit: With the threat of losing access to the PA, the doctors became much more selective in offering their patients appointments with open-access physicians.

Wetherhold takes other steps to ensure success. For instance, he holds a 'refocusing pep talk' during his twice-monthly department meetings. Such regularity, he says, can help prevent a swing back to the way things were done before. "I find that, if I don't keep constantly educating the staff - what we are doing, what we are trying to achieve, and what we have achieved - the human factor will keep pushing us back to the old system," says Wetherhold.

Of course, each institution will discover its own, similar bugs to be worked out. But, as Wetherhold indicates, it doesn't mean you have to abandon the house. In fact, loyalty to the integrity of an advanced system, and flexibility for change in the existing system, are the best exterminators.

Angela Lorio can be reached via editor@physicianspractice.com.

This article originally appeared in the July/August 2000 issue of Physicians Practice.