Scheduling: Open Sesame

When Sumi Sexton first set up shop with three fellow family physicians - Jennifer Gorrelick, Hey-Jin Kong, and Julia Stanford - back in the spring of 2003, she absolutely insisted that, along with using computerized medical records, the practice employ an open-access scheduling model to see patients. “She pretty much made us do it,” says Kong, chuckling. Four years later, Kong fully agrees with Sexton’s stipulation. “It’s working out very well.”

Before launching Premier Primary Care in Arlington, Va., the four had been working at a satellite office practice of Georgetown University Hospital, where they experienced firsthand the frustrating repercussions of working with traditional scheduling. “Despite the manager’s best efforts, patients just couldn’t get in,” says Sexton. “It was so inefficient.”

“Open access” means patients can call the doctor and be seen that day, or perhaps the next day, regardless of the reason. Sometimes known as “advanced access,” the open-access concept was conceived back in the early 1990s by Mark Murray and Catherine Tantau, a physician and nurse at Kaiser Permanente, who wanted to improve patient care by being more immediately available. Applying the axiom “Do today’s work today” to scheduling, Murray and Tantau reduced their 55-day appointment backlog to just one day. They also found themselves much more responsive to their patients’ acute and chronic needs, and they discovered that they’d greatly increased the odds of each group’s physicians seeing their own patient panel, thus improving continuity of care. Patient satisfaction soared.

Today, more and more physician practices like Premier Primary Care are embracing open access. Is it time to consider such a model for your own practice? Do you have a backlog of appointments weeks long? A harried front-desk staff that scrambles daily to appease a demanding public? Physicians who see their own patients only once out of every three visits? If so, a new scheduling model might be just what the doctor ordered to improve the daily goings-on of your practice.

The doctor will see you now

Open-access implementations vary considerably. Sexton says that Premier Primary Care uses a hybrid approach by combining both open-access and traditional scheduling concepts. “True open access is staying as late as needed to see all patients. We’re four working moms - we can’t do that,” she says. “The way our system works is you can be seen today or tomorrow, with a certain number of openings that patients can schedule in advance.”

Out of the 32 appointment slots available per physician each day, Sexton says the schedulers are trained to “leave 20 open” for same-day/next-day call-ins. She gives an example: “On Wednesday morning, the schedulers start scheduling Wednesday and Thursday, but not Friday. Friday was full a month ago.” By “full,” she means the dozen slots set aside for known purposes - a regular diabetes checkup, perhaps, or any other chronic condition needing regular monitoring.

So that’s just one derivative; perhaps it will also work for you. Or consider this rendition invoked three years ago by the six physicians and four nurse practitioners at Prime Care Medical Center in Selmer, Tenn. Here, the practice splits open-access and scheduled appointments about equally. Early-bird scheduled appointments are generally reserved for chronically ill patients, while “most others come after 10 a.m.,” says Jim King, a family physician at the practice. “We try to see all the people we can.” This means about 35 to 40 patients per provider per day, from a “monthly average” viewpoint. On a daily basis, though, you must accept the unpredictable nature of open-access scheduling, says King. “Some days I’ll be extremely busy, and other days I’ll sit around and wonder why people don’t love me.”

For the semantically exacting, it must be noted here that Prime Care’s setup is not technically a bona fide “open-access” model, as the majority of appointment slots are not reserved for open-access appointments. Rather, this model is known as a “carve out” - traditional scheduling with some open access included (carved out). Still, 50 percent is a significant chunk, allowing an overall higher physician response to patient concerns than with purely conventional scheduling.

Doin’ what comes openly

Regardless of the exact scenario you choose, expect trickle-down benefits to permeate your practice after adopting open-access scheduling, including the following:

• Continuity of care can become a reality for your patients; indeed, this was one of the driving reasons King switched over. “With traditional scheduling, I wasn’t seeing my own patients. They’d come in for something, and I’d find out they’d been in for bronchitis or whatnot,” he says. Even though he knows his patients were receiving good care from the other physicians in his group, King says that open access has strengthened the physician/ patient bond because he’s involved with all issues, both acute and chronic.

Why does this matter? Because if your patient can’t see you when he needs to, you risk both undermining his sense of having a medical home if he seeks care elsewhere, such as a retail medical clinic, and potentially missing some chain of events relevant to a new diagnosis.

• Efficiency is another area of positive impact. Just as professional organizers endorse handling the tidal wave of paper flooding our mailboxes daily, likewise with patient requests. Advance scheduling puts the onus on your staff to make reminder calls when future appointments come due - not necessary if Mrs. Bernstein can just come in today at 10 to have that annoying sebaceous cyst on her back removed. Minimize repeat contacts and shunting the patient to this or that staff person, advises practice management educator Elizabeth Woodcock. “Every hand-off, every new form reduces the time that staff can productively spend in patient care,” she says. “It is more efficient to spend time on patient visits instead of finding ways to keep them out of the practice.”

• Cost reduction is always attractive, and open access won’t disappoint. Schedule a little extra time in your appointment slots to address multiple issues during one visit, suggests Dennis O’Hare, a family physician for Allina Hospitals & Clinics in the Minneapolis area. Consider Mrs. Bernstein’s cyst: “In the ‘old world,’ you wouldn’t have time to take that off, but in the new way, you might get it all done in one visit,” says O’Hare. The vice president of two of Allina’s hospitals, Mercy and Unity, calls this “max packing,” saying, “Everybody wins: The patient saves himself another visit. The doctor can code a higher charge and can see more patients. The insurance company pays for fewer visits.”All this can certainly build a healthier bottom line. But the concept of “too much of a good thing” does apply to open access, especially since filling appointment slots can only be estimated, not guaranteed. “We try to see all the people we can,” says King, but he likes the financial security that scheduled appointments afford. I can’t have too much open access.”

• Supply and demand in terms of patient load will become more manageable. A backlog of patient appointments sometimes gives a physician the misleading impression that the demand for his services is limitless. But is this really true? Take a hard look at your appointment access gaps over time. If patients consistently waited 35 days on average for an appointment for the past two years, then your demand is actually stable. There’s no reason you can’t eliminate this chronic blockage through open access. Back in 1998, O’Hare’s clinic - the largest of Allina’s 42 clinics, with about a 100-physician staff - found this to be true. “We had gridlock,” he says. “The ability of getting into our clinic [that same day] was about a 10 percent chance, and the chance of seeing your own doctor? About 15 percent.”

The clinic’s previous 30-day backlog is now essentially zero. What’s more, O’Hare says, the clinic, due to an unexpected balance in patient supply and demand, stopped actively recruiting additional providers - previously thought necessary to accommodate an escalating crush of patients that didn’t, in fact, exist. Without recruiting costs or an additional partner, the practice now finds itself both calmer and richer.

Put it into practice

Opening a new practice? Lucky you: You’re in an enviable position for using open-access scheduling. “I would encourage all new practices to strongly consider this. It’s a really difficult endeavor once you’ve gone with the traditional model,” says
Sexton. For the rest, you have some work ahead of you to retrofit open-access scheduling into your practice successfully:

• Treat it like a project. Put someone in charge of the conversion to redesign your work processes. If patients will be coming in the same day they call, their records must be pulled that much faster. Who will do it? Devise backup plans. If you have a significant overflow on a particular day, who will stay late? Unexpected events happen; be ready.

• Educate everyone. All involved parties must shift to this new paradigm - administrative staff, physicians, nurses, and patients. As always, you’ll have to deal with the naysayers. And as always, the more information you provide, the more smoothly the transition will go. Seek out written material on the subject - you’ll find a dozen articles on our Web site alone. Apprise and train your staff thoroughly. For patients, distribute explanatory information on the new scheduling model, “go live” dates, and any other relevant information.

• Work down your backlog. This is the glut of appointments already on the docket. You must process this logjam until it is gone, and have your schedulers refrain from perpetuating the habit. Expect to work longer hours temporarily until the schedule is clear.

• Collect and analyze your scheduling data. Learn your own practice, work flow-wise. Keep track of your phone volume for a few months. What do patients call for most often? Least often? Open access can slash phone calls because patients can come in to get diagnosed and treated rather than overwhelming your nurse with phone-based triage. Determine who’s not getting into your clinic, and why - is this business you’re losing? Look at scheduling patterns: Do patient needs routinely increase during a certain time of year? What days are busiest? Also, calculate for each physician work hours, panel size, and average visit lengths. Use all of this key information to build an optimal open-access methodology for your practice.

• Do today’s work today. Invoke this basic tenet touted by open-access creators Murray and Tantau right from the start. Resolve to start on time and follow procedures. Stay flexible, but encourage patients to come in the same day they call, or perhaps the next day. Of course, some patient care must be scheduled for the future - that’s fine, as long as the situation truly warrants it. On the back end, complete any paperwork related to an appointment the same day.

• Reduce your appointment types. “Clinics typically have 50 to 100 appointment types. Open access has only three or four,” says O’Hare. Even smaller practices may have excessive categories. Strip them down to the bare minimum. Premier Primary Care uses only two, says Sexton: half-hour slots for physicals and quarter-hour appointments for everything else.

• Teach smart scheduling. Train your schedulers thoroughly but patiently. They’ll need time to acclimate to the idea of reserving a certain number of slots for open access. Like a mantra, Sexton drums “Keep 20 Open,” into her scheduling staff. They’ll adjust, and when they do, expect approval. “Our schedulers are happy as they come,” says O’Hare. With conventional scheduling and all its dozens of appointment types, “they were always getting yelled at. This is much easier now.” Make sure your schedulers put patients with their own providers as much as possible to promote continuity of care. Finally, teach your schedulers to set up follow-up visits as they normally would, taking care not to cluster appointments - you don’t want another backlog gumming up the works.

• Do regular self-checks. Stay mindful of your appointment scheduling fill rate with a quick monthly calculation: Divide the total number of filled appointment slots by the total number of available slots, and then multiply by 100 for your fill rate percentage. Ideally, this should hover between 90 and 95 percent. Exceptions happen, such as flu season, but an appointment schedule routinely packed more than 95 percent full will stress out your staff, your providers, and your patients. Conversely, too much blank space in your appointment book - less than 90 percent -will significantly affect your revenue stream and, therefore, your bottom line.

Nothing’s perfect

Any system on any subject has its downsides; open-access scheduling is no exception. For one, it makes sense that this model would eliminate no-shows (at least for the same-day appointments), but you’ll still get some, human nature and today’s fast pace being what they are. Also, O’Hare notes, for some people, the greatly simplified appointment types “may be a loss of control,” especially for doctors, who are not exactly known for embracing change.

Your administrative staff will certainly make fewer phone calls, but they’ll also find themselves explaining the open-access structure to confused patients ad nauseum, at least initially: I’m sorry, since today is Wednesday, you can’t make an appointment with Dr. Sexton on Friday at 3 o’clock; she’s booked. Call tomorrow, and then we can set something up with her on Friday - nonsensical if you don’t understand open-access philosophies. Have a written explanation ready for handing out or e-mailing.

You may want to ease your patients into the new system: Certainly, you don’t want to annoy them unduly while everyone adjusts to the new protocol. Telling a patient to call back the next day can be irksome (and you’ll be clogging up your own phone lines besides). Remember, open access is patient-centered. For the first few months, go ahead and schedule patients for Friday even if it’s Wednesday: Need an appointment for Friday with Dr. Sexton? How about 3 o’clock? Great; we’ll see you then. Before hanging up, though, make sure your staff also reminds the patient that with the new scheduling system he can now come in the same day he calls. It’ll take patients a little while to catch on, but before long they’ll stop calling in advance. Just be patient; soon they’ll embrace open access along with you.

Your staff must stay abreast of the prep work that must be done for each patient visit. Charts have to be pulled quickly for same-dayers. Establish specific work flows to handle this.

Scheduling work hours for the physicians in your practice will be challenging, because every day you’re gambling that X-number of patients will call in. Maybe they will, maybe they won’t. Yes, demand is shockingly steady when viewed on a monthly basis. But daily patient needs tend to fluctuate. Regardless, someone must be ready to handle all who walk through the door that day. This complicates taking leave. Sexton says her clinic has had its snags with this - at one point, two physicians were on maternity leave simultaneously.

Doubtless, open-access scheduling requires a collective change in mind-set within your practice. All must accept the transitory growing pains, but count on patients complaining occasionally about the new way, no matter how well you plan, train, and implement. Sexton estimates that this happens about once a week; she strives to be responsive. But you can’t please everyone all the time, and really, most issues are resolvable. Most will fade over time. What patients wouldn’t want to be seen right away, once they understand they can be? Overall, open access works, says King. “It hasn’t adversely affected revenue. We’ve generated the same number of appointments at the end of the year as before. And the patients are happier.”

Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the March 2007 issue of Physicians Practice.