Same-Day Appointments

According to a recent study of patient perceptions about healthcare, the more time their physician spends with them, the more positively patients perceive that physician and the practice overall (Medical Group Management Association/Sullivan Luallin). It seems pretty straightforward, right? But what happens when your patients can't even get an appointment to see you until three weeks from next Tuesday? Clearly, it works against your best efforts to practice efficiently -- and delivers a black eye to patient access and satisfaction.

Creating timely access for patients is a concern for many medical practices. Of course, improved access means happier patients, happier referring physicians, and greater operational efficiency. When patients with acute conditions can't see their physician on an emergent, same-day basis, they will seek care elsewhere --  from an urgent care center, an emergency room, or from your competition down the street. That costs you (and the healthcare system) money. It has been estimated that as many as 55 percent of emergency room visits are for nonurgent conditions that you could handle in your office, with better access in place.

Advanced access --  whereby practices leave their schedules open for patients who call within 24 hours of their desired appointment time --  isn't new. It originated at Kaiser Permanente in the early 1990s under the management team of Mark Murray, MD, and Catherine Tantau, RN, and is enjoying steady, if somewhat cautious, growth and acceptance. A variation is open access, in which a portion of the day's appointments are open to same-day or next-day visits.

"It's rare for a practice not to be aware that patient waits are an issue. Everybody is trying to do something about access," says Murray. "How many are trying advanced access informally? Maybe 40 percent to 50 percent [of practices] are dabbling or touching on some ideas. About 20 percent are implementing it seriously."

Problems solved!

Putting advanced access to work in your practice won't be effortless, but it will go a long way toward resolving a number of common problems that frustrate your patients and your practice. For example:

Problem: Patients want to see their regular physician for acute visits, but often are scheduled to see a covering physician instead.
Solution: When your entire practice implements advanced access, all physicians will have same-day slots available every day. Acute care patients won't be sent to the one physician covering same-day visits.

When patients are able see their own physicians, their demand for additional appointments actually decreases by at least 5 percent, according to research by Murray. "When there is a feeling of scarcity --  when patients think they can't get an appointment or contact their doctor at will, the appointment becomes the currency," he says. "The patient thinks, 'The only way I can get my needs met is with an appointment,' so needs go up." Moreover, when they see the same physician every time, patients' satisfaction and the continuity of care increases significantly.

Problem: There are unnecessary delays (and associated expenses) in responding to patient requests.

Solution: With advanced access, you're processing work on a real-time basis, which is more cost-effective and efficient. You'll find yourself spending more time on patient visits, and your staff is spending less time keeping patients out of the practice.

Here's how many practices cause unnecessary delays: an operator takes a patient's telephone message; a medical records clerk pulls the patient's chart with the attached note and gives it to a medical assistant for evaluation. The physician reviews it and has a nurse return the patient's call. This process may take an hour or an entire day to complete. Meanwhile, the patient becomes frustrated and may go elsewhere to get the care they need.

Practice resources, including a great deal of administrative and clinical staff time, are spent deflecting, rather than responding to, patient demand. "There is a perception that demand is insatiable," Murray explains. "The reaction is to put up barriers." But every hand-off, every new form, reduces the time that staff can productively spend in patient care (and billable activities).

In reality, Murray believes, "The biggest barrier is not seeing things clearly --  not understanding system dynamics. Physicians don't see how work gets done; staff has one way of working, the docs think it's another way."

Problem: Your practice's wait time to next appointment is getting longer.

Solution: Balance patient demand and provider supply, and you'll be able to see today's patients today.

A solo family practitioner cannot possibly meet the appointment demands of 20,000 patients seeking care, but can certainly meet the demands of 2,000. A practice --  no matter what specialty --  must supply enough care providers to meet the demands of the patient population it serves.

If your wait time is growing, then supply and demand are out of balance. When demand exceeds supply, the time to the next available appointment will increase over time. However, many practices have access gaps that persist over time. Say, for example, that last January, it took 45 days to schedule a new patient, and it is the same for this January. But if demand has not grown faster than the supply of appointments, there is no reason why the time to the next available appointment can't --  and shouldn't --  be zero days. More later on how to get there.

To be sure, backlogs develop over time and won't go away in a flash. If your practice finds its average wait times getting longer, consider improving efficiency and time management, or recruiting an additional provider. And keep in mind that delays may give "comfort" to some physicians: they perceive them as an indication of their popularity. But statistically, backlogs should be unnecessary if wait times are stable.

Steps toward success

Here's what you will need to do to put advanced access to work in your practice.

First, start with physicians and staff:

o Eliminate "the front versus the back" mindset. Working as a team is essential to serving the patient in a timely manner. Consider ways to speed communications, including closer physical proximity for the clerical and clinical staff.

o Empower staff to meet the patients' needs. Instead of five hand-offs for every telephone message, develop a process to manage them on a real-time basis. Since many patients will be scheduled on a same-day basis, your records staff must be able to fulfill requests rapidly; develop an effective process for record retrieval. Real-time processing of work allows you to reduce the need for rework and the inevitable errors that result from multiple hand-offs and steps (and is a good reason to transition to an electronic medical record).

o Have enough physicians to handle patient demands. If you receive word that 1,000 new patients have signed up with your practice, seek out temporary help until you can recruit a new physician. Manage vacations in a similar fashion: everyone on staff cannot go on vacation at the same time that patient demand peaks (e.g., flu season).

o Work through the backlog. In order to implement advanced access, your practice must first eliminate its backlog of patients waiting for appointments. If your time to next available appointment is five weeks away, it will likely take your practice five to six weeks to accomplish this.

o Decide how you will accommodate individual patient needs. You may have a patient who calls from the lobby or one who requires an authorization from the payer that will require 24 hours. If you're a specialty office and you need a day to process referrals in order to get paid for your services, then you may base the concept of advanced access around next-day instead of same-day availability.
 
Next, you may have to modify some old habits:

o Start on time. For real-time work processing to create efficiency, your practice must start its office hours on time.

o Prepare for variability in your day. There may be days that you need to stay late to meet your patients' needs. On average, however, your day will be shorter with advanced access because you're eliminating waits and delays.

o Eliminate multiple appointment types. They become irrelevant under advanced access (although you should continue to distinguish new patients from established patients for administrative and clinical purposes.)

o Schedule follow-up visits with patients as you normally would, but be sure they aren't clustered. That is, if you find that patient demand is higher on Mondays, schedule follow-up visits on another weekday to leave room for same-day appointment requests.

o Schedule patients with their chosen providers. The continuity of the patient-provider relationship is essential to advanced access. Midlevel providers should have their own panel of patients, but they can serve as back-ups to physicians when demand exceeds the availability of appointments. Part-time providers should team up so they can function as a full-time provider. Be sure that patients know that the part-timers are a "team."

o Plan for the visit. Seek accurate information when the appointment is scheduled to prepare for the visit. Tell the patient: "Dr. Smith wants to be prepared for your visit tomorrow; can you tell me what you are coming in for?" Look in the chart for upcoming immunizations, well-woman checks, and so forth. Meet with your staff at the beginning of each clinic session to anticipate patients' needs. "Pull" the work into today.

o Complete the visit. Don't deflect work until later in the day. Dictate the note, finalize the paperwork, send the referral, or transmit the prescription to the pharmacy when the need arises. Remember, real-time work is more efficient than batching work. It can reduce the length of your workday. Consider increasing the interval between appointments (for example, from every 15 minutes to every 20 minutes) to include paperwork.

Finally,

o Before and while you are making the change to advanced access, educate the stakeholders of your practice. Everyone --  from patients to physicians --  needs to believe in it. Providers will be anxious about open schedules when they walk in every morning. Staff will almost instinctively want to deflect demand, thinking that they are "saving" you from extra work. Patients may be confused about why they can suddenly be seen on the same day.

o Greet walk-ins with information regarding your new approach to scheduling. Knowing that they can be seen on a same-day basis will influence their behavior next time.

Advanced access offers a useful solution to a problem that is growing worse as physician practices struggle to see more and more patients. But it requires a change in approach and in thinking. Says Murray, "In healthcare, what we've done is try to put the burden of variation on the patient. If I'm seeing 20 patients a day, and 22 call for appointments, I make the rest of them wait. Other industries don't do that; they recognize the variation in demand needs to be absorbed by the business."

While moving toward advanced access requires effort on everyone's part, the rewards will be more satisfied patients, better continuity of care, and a more efficient practice. "When we reduce waiting time, good things happen. Patients and staff are happier, and it helps the docs," Murray says. "It's an opportunity to take care of people without all the clutter of rework and redundancy and being behind in our schedules. We take care of them better."

Elizabeth W. Woodcock, MBA, FACMPE, is director of knowledge management for Physicians Practice, and a former consultant with the Medical Group Management Association (MGMA) Health Care Consulting Group. She can be reached at ewoodcock@physicianspractice.com.

This article originally appeared in the January 2004 issue of Physicians Practice.