Open Access Scheduling Study

A new study in the Annals of Internal Medicine used case studies to review the outcomes from open access schedules. The study is just a case series so it's subject to the normal bias that comes with it but the outcomes where mixed.

Go to Canadian Medicine for a complete review of the study and a Canadian perspective. Based on the review that I did of open access management changes are just as important as the scheduling changes. Without control of the variation in need, provider availability and length of appointment you're sunk.

The End of Open Access Week

It's the end of "Open Access Week" at Wait Time & Delayed Care so I thought I'd offer a summary and a little syrup. Check out the testimonial from a physician's office in British Columbia, Canada at this link.

For a review of different schedule types click here:
For Part 1 - Overview of Open Access and an example click here:
For Part 2 - Discussion about Wait Time & Capacity click here:
For Part 3 - Critical Analysis with a short literature review click here

The point of the series is not to convince the reader that open access is the only way but I do think it could work well on a large scale and in primary care. If you have questions feel free to comment or email me at ian underscore furst at yahoo dot com

Ian.

Open Acces: Part 3 Analyzing Open Access Scheduling

Today is the final installment of my series on open access scheduling. In part 1 I reviewed an implementation of Open Access Scheduling at Baylor College’s Family Practice Unit in Houston, Texas. In the second part of the series I discussed the theoretical relationship between wait time and total capacity. Today, I’ll take a deeper look at some of the management changes required to implement open access and undertake a more scholarly critique of the concept.

One of the first major articles about open access was from the primary care department at Kaiser Permanente in northern California as a means to decrease wait times in the clinic. The premise of open access is that today’s work is done today by offering all patients appointments for either the same or next day. Open access can function with zero wait time because most practices are in a state of equilibrium where the patient demand is roughly equal to the supply of provider time. The prerequisite for open-access, however, is careful management of resources and patient demands to maintain a uniform level of each with as little variation as possible.

At Baylor, Dr. Steinbauer and his team leveled the requests by patients for appointments using several techniques. Provider schedules were made accessible to the patients, the number of appointment types was decreased from 30-50 to 2-3 and allowances were made to triage/treat patients based on a phone assessment during flu season. This was combined with a patient education program.

On the practice management side, the team maintained the usual staffing levels, established rules for provider leave, developed a system for reminding patients of necessary appointments and reengineered the scheduling processes around health maintenance appointments (see last post for details on this change). The concept of better practice management to facilitate open access is not unique to the Baylor experience. In reports of open access implementation, management changes play a major role in the descriptions.

This raises the question of whether or not it is the scheduling or management changes that lowered wait times. In fact, a recent study from the UK used a single-blinded trial to compare 24 open access to 24 non-open access clinics. There was no significant difference between wait times in the two clinics. However, both had very low wait times for an appointment (1.00 vs 1.87 days). Whereas a Minnesota medical group conducted a longitudinal study between 1998 and 2002 comparing non-open access (1998-2000) to open access (2000-2002). They had a 38% increase in capacity (WRVU’s), PCP compensation rose 20% and costs fell 20% (cost per WRVU fell 13%). The context of the experiment, however, was observation during a period of organizational restructuring which happened to included changing to open access. These studies suggest that management rather than schedule alone is responsible for many of the benefits of open access.

Regardless of the cause, the overall effect seems to be a more efficient clinic. But if the same changes where made in a clinic that used block booking which would have greater capacity? There is no clear cut answer as of yet. Theoretically, offices with zero wait times will have a capacity lower than that of those with slightly longer wait (assuming there is some variation to the patient mix). But actual open access practices realize a capacity (total patient volume) near averages with standard scheduling types. It may be that better management makes up for the lack of a buffer of patients. When I asked Dr. Steinbauer if the total number of patients in the practice increased with the open access implementation he responded, “I didn't track the number of total patients in the practice. But with the increased availability of slots (and no increase in visits per patients; i.e.., we weren't "churning") I assume we got more patients.”

It may also be that that allowance for appointments’ up to 14 days out is enough of a buffer to reach 100% capacity. According to Dr. Steinbauer, “We tracked a metric called "percent capacity usage". Simply the number of patients seen over the available appointment slots expressed as a percent. We maintained appointment filling at 95-105% during and after the transition. There were more patients seen by the physicians because there were fewer long appointment slots, and therefore, more appointments available”.

It has been the experience of my own clinic that even when open access appointments are offered there is a tendency to choose 7-10 days to make allowances for work, car rides, etc…. My final assessment of open access is that it by itself it confers neither a net benefit nor loss in total patient capacity.

The effect on patient satisfaction with open access is unequivocal. Almost all of the reports have conducted patient satisfaction surveys which show a definite improvement. Interestingly, in a more recent survey of 10,821 patients in the UK found that the day of choice was more important than immediate access. This further supports the idea that a 14 day buffer may be beneficial by maximizing patient satisfaction and improving capacity.

The effect on follow-up is mixed. As anecdotally described by Dr. Steinbauer follow-up is less likely to occur because the patient leaves the clinic without an appointment. His group, however, did not track a follow-through metric. The number of appointments each patient used each year (2.7) did not change which is suggestive of similar follow-through pre and post implementation. Another way to examine the problem is realized access. That is how often a patient actually makes use of the open access system. In the words of Dr. Rohrer of the Mayo Clinic “…. other clinic characteristics may overcome the effects of open-access scheduling”. Dr. Rohrer’s group also found the realized access to care did not correlate to the use of open access scheduling. A third study by Dr. Sperl-Hillen et al., from Minnesota found better care in the management of diabetes (as characterized by better control of HbA1c and LDL) with open access but there was no correlation to wait time. This is suggestive of better realized access due to the effect of better management rather than schedule type. Finally, our own clinic sees follow through rates anywhere between 55%-95% depending on the procedure. However a clinic reminds patients of follow-up, the system should be rigorous so people don’t get forgot regardless of whether or not they leave the office with their next appointment.

In the end, I’m left to conclude that open access scheduling could well be an answer to some of the primary care access problems. It is a simple tool to effectively manage a primary care practice. Based on the evidence, it maintains capacity, nearly eliminates wait time and improves satisfaction. A well managed practice could have many of the same results using the benefits of block booking but open access is a straight forward means to achieve similar (or better) results.

For more information on open access take a look at Dr. Kishore Visvanathan’s site who has been posting his the results of his transition to open access as they occur.

Part 1: Open Access Scheduling: Interview with Dr. Jeffrey Steinbauer
Part 2: The Relationship between Wait & Capacity

Open Access: Part 2

The Relationship between Wait and Capacity

In Part 1 of my series on Open Access scheduling I posted about an implementation of open access at Baylor, Houston. Today I would like to take a closer look at the issue of practice capacity. Open Access scheduling is characterized by near zero wait times. One of the central arguments for it is that there can be zero wait times with the same capacity as a standard scheduling model. This is embodied in the motto; “Do today’s work today”. Since I believe that open access could be a major improvement to our health care system the relationship between capacity and delay deserves its own post.

Once an office is in steady state (the same number of patients are entering and leaving the practice) the wait time is proportional to the amount the system is utilized. If an office has 5 people per day seeking appointments, there will be zero delay. If it has 300 requests there will be considerable delay. After 3-5 years most offices enter a steady state where the demand for appointments is met by the supply of provider time. It is at this point that the wait time can be reduced to near zero.

In most queuing models delay begins at approximately 80% capacity. The point at which capacity is saturated without incurring delay can be pushed further to 100% by better efficiency and increasing the overal size of the system. Imagine two offices, each running at 90% capacity. Office A has more providers than Office B. Office A will have a lower wait times than Office B if all other factors are equal. Now imagine that the offices are the same size. If Office A is more efficient than Office B it will also have lower wait times.

The issue of efficiency is also central to the concept of open access. In order to have zero wait times, and maintain the same capacity, the office must be highly efficient. Efficiency, in this sense, is defined as the amount of variation in supply and demand for patient appointment slots. The variation in demand for appointment slots will be created by the patient. In flu season, for instance, the demand for appointments will spike. The variation in the supply of appointments will depend on how appointments are booked (short, long, variable length) and the availability of providers. The greater the variability in supplier demand, the lower the efficiency of the office.

As I write about capacity, therefore, the assumption is that all offices run at under 100% capacity because variation in patient demand and provider availability exists. I can also assume that all practices are capable of running with zero wait times below 80% capacity. So the real argument to open access versus conventional booking is at what point between 80-99% capacity wait occurs with good practice management. If open access offices had lower capacity compared to standard models, practices using it would have a lower total patient count and openings in the schedule. Instead, the data is strong that, in primary care, an open access schedule can handle the same capacity as a standard schedule but with zero wait times (which dramatically increases patient satisfaction). Tomorrow, I’ll be taking a closer look at experiences and data to support this contention and discuss the potential pitfalls of open access.

Part 1: Open Access Scheduling: Interview with Dr. Jeffrey Steinbauer
Part 3: Analyzing Open Access Scheduling

Open Access Scheduling: Interview with Dr. Jeffrey Steinbauer

Part 1: Review of an Open-Access Implementation

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

Open Access Scheduling

Next week I will be posting a two part interview with Dr. Jeffrey Steinbauer, Medical Director, Baylor Clinic, Houston, Texas and former Director of the Family Practice Unit. Dr. Steinbauer instituted open-access scheduling in 2003 and has published the results of his clinics implementation.

Countries around the world are identifying primary care access as one of the major hurdles to health care reform. In the US, reform will increase the demand on primary care and in Canada primary care access has been a problem for the past 10 years.

Open-access schedules have been touted as one possible solution to the influx of people seeking primary care. I wanted to get Dr. Steinbauer's impression of the benefits and pit-falls to open-access and compare it to block booking.

Phone Screening & Open Access (Same Day) Surgery

Let me preface this blog by saying that I believe our clinic runs efficiently. We are a specialty clinic where patients are referred from generalists, seen for consultation then booked for surgery if needed. After doing a process flow map from the patients’ perspective we realized there was a group of patients that could have their consultation and surgery on the same day.

Having a consultation and procedure for surgery completed in one appointment saves the patient two trips to the clinic (including two sets on phone calls, in-clinic waiting, etc….), and the clinic from having to organize two appointments. Of course, a certain percentage of these people will arrive expecting to have the surgical procedure completed and it will not be required, thus wasting a surgical appointment.

The corollary is that when surgery is completed with more than one appointment there is the potential that the patient will not follow through (thus wasting a consultation appointment), that the appointment will be forgotten, that there will be an administrative error causing missed or forgotten appointments or another type of error that introduces wasted time. Multiple appointments, however, ensures that all surgical appointments booked are truly required.

We decided to put the theory to the test that having strict phone screening of patients that were referred for open access appointments (same day surgery) would decrease workload. The list was very simple – the patient is not on wafarin (a blood thinner), they don’t need pre-op antibiotics, they can have it done under local anaesthetic and a few others. If the patient met the criteria they were booked for surgery and consultation the same day. We did this for 10months then compared those patients to a group from the corresponding 10 months in the previous year (prior to having the list in place).

What were the results? In the study period 2627 patients were reviewed and compared to 2187 patients in the ‘control’ period (for the purists out there we also studied the demographics and compared them using t-tests and chi-square analysis; they were the same). An additional 3% of patients (100) had their surgery done the same day (p=0.000003 for the statisticians) which was a very significant difference. Now 3% may not seem like a lot but it saved us a total of 25 hours worth of work on the surgeons part and days of waiting on the patients part. It also opened up 25 hours worth of time for other patients, thereby decreasing our wait time for everyone.

Did we find any surprises – yes. As I’ve mentioned in other posts, 5.5% of patients did not follow through in both groups. One would assume that as more patients had same day surgery the non-follow through group would diminish but we didn’t see it. I don’t think this is a statistical glitch, I believe that there is a group of patients that are reluctant to follow-through and no matter how you book them it won’t happen.

The take home message is that working to condense appointments can save the clinic and your clients’ time. The effect is exponential for the administrative staff because every additional appointment adds work before and after especially when appointments are missed or moved. Have strict written criteria and reinforce it rigorously.

Amendment to this story as of May 23, 2008: We have had to add the biphosphonate group of drugs to the list of those that can't be booked for open access because they need a 3 month drug holiday.