Group Practice Lowers Wait for Consultation

When you refer a patient to a specialist, how long should it take to get a consult? The wait time for a doctors office partly depends on how the partners of the speciality practice have arranged their partnership. Most practitioners will be familiar with a group practice either being cost share, where you each have an individual practice but share expenses or a true partnership. The value of a true partnership is that patients can choose to be referred to either the partnership or an individual doctor.

Kishore at Plain Brown Wrapper is a urologist and has been working on an advanced access program to decrease wait times. He discussed with his partners allowing referrals to be defaulted to the entire partnership unless otherwise specified. The result: a significant drop in wait times for consultation. He presents the data here.

Our practice does the same (and has for years). When a referral comes in (email, fax, phone) and "initial contact" is made which specifies which doctor will see the patient and whether or not that doctor has been specified as the only provider (eg. No substitutes). An example of the difference is in the request for a basic consultation (15min). The data below shows that when the "only provider" option is selected the wait is 50% longer (19 vs 14 days) and the standard deviation 15% longer. When the consultation is longer, the wait times grow and the difference becomes even more stark.




Merging referral management and scheduling technology is critical to making this process work and it is not an easy task. We've run into minor problems in unifying phone, fax and email referrals but other than that the EMR technology has been problem free for referral management. The bottom line is that a true group partnership lowers health care wait times.

Group Practice Levels Scheduling

Do you ever get pissed-off at a colleague because you’re positive you’re working harder or seeing more patients? Nah – me neither. I then read an article at Curious Cat Management about computer programmers and how they can have an order of magnitude (10x) difference in productivity while writing code and that it’s unrelated to skill or experience and I started to wonder if we had the same amount of variation between doctors.

I understand there is a difference in creative work versus menial work (and pulling teeth is menial) but I started to wonder what the difference would be in our own practice. We have an agreement between the doctors that we set global guidelines (block booking) for the schedule in conjunction with our staff & managers then let the front desk run with it. There are, of course, ups and downs and constant critiques but the blocks of time are set 3-4 times a year.

In OFFICE1 there are always multiple surgeons present. In OFFICES 2, 3 and 4 there is only one per day. I had a theory that there would be more pressure in OFFICE1 to conform to the scheduling guidelines. This would result in less variation in the number of appointments per day in OFFICE1 with more variation in OFFICES 2, 3 and 4. In other words, some of the doctors would have more variation in efficiency without peer pressure.

I pulled data for the year 2007 (251 days, 4 offices, 5 surgeons) and compared all offices and doctors. I then preformed multiple statistical tests to prove my theory. To my surprise, there is no difference in the amount of variation per office between doctors. In fact, when you compare each doctor in each office there is absolutely no clinically significant difference over OFFICES 1, 2 and 3. OFFICE 4 is smaller, so we expect to see fewer appointments but it’s uniformly less between the doctors. Putting numbers to it, if we have an average of 22 +/- 5 appointments per day, there is a variation of 0.8 appointments that can be accounted for by a different doctor. That is a whopping 4% of the variation. Compare this to the 10x seen in computer programmers. In fact, the total amount of variation in the average number of appointments seen per day is 7% for all four offices or 4% if OFFICE4 is excluded.

From this data I conclude that:

• We all have the same number of appointments and there are only modest differences between the offices


• That there is statistically no difference between the doctors in the number of appointments


• Setting scheduling policies globally has a profound effect on minimizing variation.


• Group practice applies another major pressure to work efficiently to the standards & expectations of others in the group.

I cannot stress enough the effect of minimizing variation (or leveling a process). It is the single biggest factor in poor patient satisfaction (because some patients will be left waiting much longer than expected) and resources planning. It is much easier to manage a practice when you know that the error on the number of appointments will be +/-0.8 instead of +/-10. In this case we’ve used good lean principals to level a process (scheduling) and block booking which increases efficiency. With the marriage of technology and good practice management this minimizes the health care wait times in our office.

Group Practice Lowers Wait Times

Do larger group practices’ lower health care wait times? The short answer is yes and the proof is below. First, when someone arrives or is referred it is easier to accommodate them. Second, larger organizations have economies of scale that increase efficiencies. I’ve posted the graph below a couple of times, but it’s an important one. As utilization increases so does wait time. The relationship is driven to the right (increased efficiency) by a larger organization and lower variation.


In addition, if patients are willing to accept different providers, they will wait less time. Our office receives greater than 13,000 referrals for treatment from GP’s each year. When each person is referred they (or the referring office) are asked if they want a specific doctor or the first available appointment. For most cases (93%) any provider is acceptable. But does the other 7% wait longer, because they ask for a specific provider? We studied the question by data mining 5445 records for patients over a 3-year period (2005, 2006 and 2007) for 5 providers, in 1 office for a single type of consultation (in this cases a minor procedure in the office under general anaesthetic). 382 of the patients (7%) were marked for a single provider only (in other words they only wanted to be booked with a specific doctor). On average the group that requested a specific provider waited 7 days more (20 days instead of 13) and had a greater amount of variation in the amount of time they waited (17 instead of 14). A graph of how each patient group was distributed by days waited is below.



The group that wanted a single provider only waited 51% longer and had 18% more variation in the time they waited. This is why, group practices lower wait times.