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Scheduling: Giving Physicians Carte Blanche Won't Work
Patient access to care has become problematic. One way to address this is to standardize scheduling procedures.
I am working with a multi-disciplinary group next week on a project for our primary-care clinics on patient access. Specifically, the lack of reliable access for patients in our clinics. Without a doubt, this is a nationwide problem as we wrestle with physician shortages, especially in primary care, increasingly complex patients, expectations that things occur when we want them to, and increased recommendations for screening examinations, testing, and so on. Within our system, we identified a major contributing factor to poor access: provider variation.
When we discuss provider variation in scheduling, it involves many aspects. First is just the overall appointment length. Some of my colleagues can see a patient every 15 minutes, some need 25 minutes or longer. Some providers see a patient at the same time increment (i.e., every 20 minutes) regardless of the reason for the office visit, while other providers (myself included) adjust the time needed based on the visit type (i.e., a Medicare wellness visit is 40 minutes and a well child visit is 20 minutes). Some providers have simple rules (e.g., no more than four physicals per day) and some have complex rules (e.g., cannot schedule physicals back to back, unless patients are related, or it is the third Tuesday of the month). Wherever variation exists - whether that is in appointment templates, or management of ischemic heart disease, there is increased risk of inefficiency and error.
When you are faced with a limited resource (provider time), it is imperative that errors in scheduling are reduced and that the provider's time is used as efficiently as possible. So, one solution is to analyze the data and determine the most common way of seeing patients and mandate that every provider do it the same way. The pros are that it is simple and reduces variation. The cons are that it may cause frustration among providers and may not serve the practice style of individual clinicians. Another way is the way things have traditionally been done - the doctor decides how and when he will see patients and the office staff and patients conform. The pros are relatively more satisfied clinicians, but the cons are numerous and include the increasingly prevalent issue that patients expect healthcare to adopt a "retail" mindset. My suspicion is the best solution is somewhere in the vast middle between these two extremes.
In order to reduce variation, it is essential to understand why it exists. Personally, I establish my schedule based on several factors. First, I know that I cannot do what I consider to be a complete physical on an older patient in 20 minutes. Sure, I can do the visit in 20 minutes or even 15, but neither I nor my patient would be satisfied with the result. So, I do my best to estimate which appointment types need to be long (40 minutes for physicals for patients 40 and older) and which can be short (most chronic disease follow-up visits and acute visits). I also consider my family's schedule. I'd rather be home with my kids in the afternoon and evening than in the morning, so I choose to start clinic early two days each week. Stability is of tantamount importance to our family's schedule, so I work late every Tuesday, whether I am on call or not, so my clinic hours are the same. I also consider what my office staff can support. I can do physicals all day long, back-to-back, provided I have the correct amount of time scheduled, but my medical assistant will be very unhappy and probably be running behind because of all the immunizations and mammogram scheduling she'll need to do.
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