Open Access Scheduling could well be the answer to the primary care crisis in Canada and the United States, but not for the reasons you might think. In many areas people can not get a family doctor and once they have one, can’t get in for an appointment. It was recently reported that only 10% of doctors in Ontario are accepting new patients.
Open access scheduling, otherwise known as “same-day scheduling” or “advanced access scheduling” is where primary care providers book and see patients on either the same or next day. The major benefit is zero health care wait times. When I reviewed the concept of open access and compared it to standard models such as block booking it was not lost on me that wait times in any queuing system (electronic or human) are proportionate to capacity. A queue will start to occur at approximately 80% capacity but can be pushed further to the right (closer to 100%) by maintaining low variation (see graph). If there was wide-spread adoption of open access would it lower the capacity of the entire system?
Because open access scheduling has zero office wait times it must run at less than 100% capacity. But does it run any less efficiently than an office running standard schedules? In fact, the offshoot of open access is that in order to implement and maintain it, very stringent management and lean concepts have to be employed. In other words, open access forces providers to better practice management. To learn more I contacted Dr. Jeffrey Steinbauer, Medical Director, Baylor Clinic, Houston and former Director of the Family Practice Unit. In 2003 he and his colleagues instituted open-access scheduling and have published the results of the Baylor Family Practice Units’ implementation.
According to Dr. Steinbauer, open access scheduling is a great tool for a clinic where the patient base is reasonably stable. The groups that can be defined as stable are broader than one might think. For instance, any practice that is older than 5 years typically has a mature patient base and even though there is an influx and efflux of returning patients, the number seen each day is stable. Dr. Steinbauer states that “if a practice is fairly mature and there is a steady stream of patients you can use open access by just getting rid of the “warehouse” of patient appointments. By eliminating the warehouse of appointments, he is referring to working through the back-log of patients that are currently on the waiting list. Back-log elimination requires a plan and schedule of its own and can take months to eliminate in a large practice.
When a patient requests an appointment, he or she is given the current day, the next day and in few special instances an appointment up to two weeks out. At the start of a typical day only 50-70% of available slots are booked. But if the patient needs follow up in a month, 3 months or a year, that patient is added to a recall list and called when the time comes or simply told to call back. Those reading this from the dental community are taught early on that a patient should not leave the office without his or her next appointment (to improve follow-through on recall appointments). When I asked Dr. Steinbauer if the lack of the next appointment altered the follow through rate he answered;
“Absolutely. If I ask someone to come back in 3 months he or she is more likely to return in 6 months or a year. In a traditional appointment model, many patients with chronic disease may not be getting timely follow-up.” But he also stated that better recall regimes could rectify the problem.
Of course, the prerequisite to open access scheduling is a reliable provider base and a steady stream of patients with uniform appointment lengths. The greater the variation in provider availability or patient demand, the harder it is to implement.
“Management becomes the regulator of provider availability to stabilize situations. We might have to increase providers during flu season or make accommodations to evaluate patients by phone”. Tied to that is the concept of appointment types. The greater the variation in the duration and type of appointments the more difficult same day appointments are to arrange. Baylor decreased the number of appointment types from 30-50 to just 3 (short, long and special). Special appointments are those that required a procedure length of variable duration.
Of course, change does not come without some growing pains. “Health maintenance is a frequent appointment type in our practice. Previously, the patients would see the doctor first for all health maintenance visits. This filled the doctor’s schedule with long appointments. Therefore, the nurse practitioner would end up seeing the chest pain [urgent] patients. It was ludicrous. We re-engineered appointments to remedy the situation by having the nurse practitioner see the health maintenance patients for the long first visit then the doctor only for those that needed follow-up at the short second visit. This increased doctor availability. There was some push-back from patients in the first 6 months but once they got used to it there was no problem with this system”.
Open Access scheduling has been running strong for 5 years at Baylor, Houston despite clinicians that split their time between clinic and academics. In the next post, I’ll dissect some of the deeper issues associated with open access such as follow-up care and capacity.
Part 2: The Relationship between Wait & Capacity
Part 3: Analyzing Open Access Scheduling
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