Open Access Scheduling

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Open Access Scheduling
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Charles Clemens M.D.Medical Chief of StaffSIUC
Student Health Center

• Disclosure
• Nobody pays me nothin to do this

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Internet Addresses for Power Pointon Open
Access Scheduling

• The Notes
• http//www.cwclemens.com/Chuck's Handouts.pdf
• The Power Point
• http//www.cwclemens.com/OpenAccess2006.ppt

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Residence of Students, Fall 2005 Illinois

16,823 California
390 Florida
371 Missouri
333 North
Carolina
177 Washington
165 Indiana
139 Tennessee
131 South Carolina

112 Virginia
107 Wisconsin
105 Other states
1,384 International

1,204 Total
21,441 SIUC enrolled students
from each of the 50 states, plus the District of
Columbia, Puerto Rico and other U.S. areas. Of
the total enrollment, 78 percent were from
Illinois, 16 percent from other states and 6
percent from other nations.
Enrollment Data, Fall 2005 On-campus, Carbondale
18,863 On-campus, Springfield 261 Total
19,124 Off-campus, military programs 2,311 Off
campus, Japan 6 Total 2,317 Total enrollment
21,441 Graduate/professional students Male 48.3
2,290 Female 51.7 2,454 Total
4,744 Undergraduate students Male 57.2
9,555 Female 42.8 7,142 Total 16,697
Race/Ethnic Enrollment, Fall 2005
White Black Hispanic
Asian Other Undergraduate 11,788
2,748 593 340
1,228 Graduate 2,459 424
87 58
1,043 Professional 521 42
12 45
53 Totals 14,768 3,214
692 443 2,324
68.9 15.0 3.2
2.0 10.8 Average age of undergraduates
23.7 years Average age of graduate students 31.2
years
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Student Health Center

• Medical Clinic Facts
• Providers
• 15 on staff
• 4 Family Physicians
• 1 Family Physician/ Emergency Room Specialist
• 1 Internist
• 1 Psychiatrist
• 1 Psychologist
• 2 Sports Medicine specialists
• 3 Family Practice Physicians Assistants
• 2 Rotating Orthopedists
• 8.5 Primary Care FTEs on any given day
• Nurses
• 22 Full Time in Clinic
• 15 Direct Provider Support
• 3 Travel and Immunizations
• 1 Dial a Nurse
• 1 Infection Control and Admin Support
• 1 Appointments

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• Originally Described by
• Mark Murray, MD, and Catherine Tantau, BSN, MPA
  now of Dartmouth Univ.
• First developed and applied
• in the early 1990s at Kaiser Permanente where
  Murray and Tantau were working at the time.

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• Every system is perfectly designed to get the
  results it produces.
• Paul Batalden, MD.

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• "If we keep doing what we are doing, we will keep
  getting what we got
• -Yogi Berra

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• The three most common types of scheduling systems
  utilized are
• the traditional model
• the carve-out model/first generation open access
• and open access

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• The traditional scheduling model is the most
  commonly used system in the U.S. It operates
  under the assumption that each morning, the
  schedule is full (saturated) with routine cases.
  Urgent cases are accommodated by double booking,
  overtime or running behind.
• Under this system, the average waiting time for a
  medical appointment in the U.S. is at least 3
  weeks.
• The traditional scheduling system accommodates
  the demand for appointments with a restrictive
  and complex categorization system.
• According to Murray and Tantau, the motto of
  these systems is, "Do last month's work today."

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• In an attempt to improve the traditional model of
  scheduling, a "carve-out" model, also known as a
  "first generation open access" system, was
  developed.
• Under this model, scheduling is based on
  "holding" a quantity of urgent care appointments.
  The quantity held is based on the predicted
  demand for these types of appointments.
• The motto of this system is "Do some of today's
  work today."

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• The disadvantages of this carve-out model are
  many. Although it does accommodate some urgent
  care needs, it often cannot accommodate those
  patients who need a visit "today".
• Instead of simplifying the appointment scheduling
  system, yet another category of appointments is
  created (those patients who can not wait weeks
  for an appointment, but can not be accommodated
  in the schedule "today).
• Staff may also be pressured to "steal from" spots
  held in the future, in order to fit in patients
  who do not seem to fit into the complex system

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• The third type of scheduling system, open access,
  is also known as advanced access or open
  scheduling.
• Open access removes the distinction between
  urgent and routine visits, following the motto,
  "Do all of today's work today."

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• Open-access (or advanced-access) scheduling
  involves "doing today's work today" and seeing
  patients on the day they call for an appointment.
  Mark Murray, MD, and Catherine Tantau, RN, MS,
  creators of the open-access model, offer these
  tips for success
• 1. Begin offering all patients an appointment on
  the day they call your office, regardless of the
  reason for the visit.
• 2. If patients do not want to be seen on the day
  they call, schedule an appointment of their
  choosing. Do not tell them to call back on the
  day they want to be seen.
• 3. Allow physicians to pre-schedule patients when
  it is clinically necessary ("good backlog").

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• 4. Reduce the complexity of your scheduling
  system to just three kinds of appointments
  (personal, team and unestablished) and one
  standard length of time.
• 5. Make sure each physician has a panel size that
  is manageable, based on his or her scope of
  practice, patient mix and time spent in the
  office.
• 6. Encourage efficiency and continuity by
  protecting physicians' schedules from their
  colleagues' overflow.
• 7. Develop plans for how your practice will
  handle times of extreme demand or physician
  absence.
• 8. The demand for unnecessary visits must be
  reduced. This may be accomplished through a
  variety of strategies, including eliminating
  advance scheduling of follow-up appointments
• 9. Reduce future demand by maximizing today's
  visit.

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Not all Open Access Systems follow the precepts
as conceived

• Many fail to assign Primary Care Providers
  (PCP)
• Are really Carve Out systems and dont
  understand principles of true Open Access
• Run well overtime routinely and overbook all
  providers
• Many fail to attempt continuity of care
• Have Urgent Care systems or even call in temp
  help or have administrators go to clinic

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• The standard pattern of demand is that it
  increases very quickly in the morning, flattens
  at about 10 a.m., drops over lunch, and then
  drops precipitously from about 2 p.m. on through
  the afternoon. The demand for appointments after
  4 p.m. constitutes about 4 percent of total
  demand per day. (Note that when physicians see
  patients in the late evening and night, often
  that demand was created earlier in the day but
  was deflected when the practice did not have
  earlier open appointments.)

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Students Are Different

• They sleep late if possible

• They call between or after classes

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So in Student Health

• Calls are brisk at the start in morning

• Theres a drop off during lunch hour

• Calls crescendo as the afternoon progresses to
  closing time

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Student Health Real World (Before Open Access)
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Or at least thats what weve always assumed

• Given the ability to get an appointment easily
  the first time they call,
• The pattern of calls is different

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First semester of Open Access
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Spring 2006
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• When busy physicians think about going to
  same-day scheduling, their biggest fear is that
  they'll be inundated with patient visits. But
  that shouldn't happen, unless a doctor's panel is
  too big.
• According to Charles Kilo of IHI, 0.7 to 0.8
  percent of a doctor's patients will call for an
  appointment each day.

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• The panel size for a full-time family physician
  taking care of his or her own patients in a
  mature system can be up to about 2,500.

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• Panel size can be estimated as equal to the
  number of unique patients seen in the last 18
  months

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Perils in Calculating the Panel Size per Provider
in a Student Health Service

• We ran this formula and then added the panels up
  of all providers.

• This number was 3 times the enrollment of the
  University

• The same student had seen several different
  providers. (Thus the need to identify primary
  providers.)

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• Instead, we had to count unique patient visits to
  the practice as a whole and divide by the number
  of FTE providers.

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Automated PCP Assignment January 2005
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Provider Panels May 2006
Total 19006
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• The point at which backlog has been reduced to
  good backlog varies by community. At many
  clinics, good backlog will be in the range of
  20-30 patients per 1000 beneficiaries.

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• The question as to the feasibility of
  implementing open access at a given facility is
  best addressed by looking at the demand patterns
  for the busiest months of the year.
• The reason is that ultimately, to maintain open
  access means to be able to meet the demand for
  care on a daily basis. The days that test the
  limits of a clinics capacity are Mondays and
  Tuesdays during the busiest months (e.g. January
  and February) and after holiday weekends.
• If it is projected that in most instances, the
  level of demand on those busiest days can be
  handled by the number of providers usually
  available then it is reasonable to consider
  implementing open access.

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• The trick is to measure demand accurately.
  "That's different from how many patients you
  currently see per day." says Brodsky.
• "For three weeks, we tracked how many people were
  calling, and found the number was manageable,
  given our provider capacity.

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AXIOM

• You cant use Open Access if you dont have
  access in the first place.

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• Percent same day work. This is the best measure
  of access improvement using open access
  philosophy of doing todays work today.
• This measure is obtained by counting all
  appointment requests for a given day and noting
  what percentage are booked for the day on which
  the appointment was requested. If this
  measurement is done periodically, it is best to
  measure it early in the week.
• Baseline levels are variable, depending on the
  amount of acute minor illness/sick call work that
  a particular community demands.
• This can vary form 30 to 60.
• With the implementation of open access, most
  clinics will increase the of same day work by
  at least 20. If they start at 30, they will go
  to 50. If they start at 50, they will go to
  70.

See Notes
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Schedule as used Spring 2005
18/26 same days 70/30 split
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Redone Schedule for 2005Note additional
Prescheduled slot per ½ day
16/26 same days 62/38 split
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Redone Schedule for 2006Note Reassignment of
Prescheduled slots toward Wed / Thurs
42
The Pap Smear Error

• When we first began Open Access we had a large
  volume of requests for Pap Smears. (We had
  previously been limiting these to 2 each AM and
  one each PM).
• We became fearful that there would be no time for
  other types of visits

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• I initially chose a reaction to fall back on
  limiting the number of Pap Smears done per ½ day
• After 24-48 hours reflection, I realized that
  this was a violation of the basic precepts of
  Open Access
• I had to formulate a carefully worded letter to
  staff explaining my error.

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• We opened up to no limits on Paps
• Within 3 weeks we slowed back down to steady
  state of 2-5 Paps per day per provider.

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For Fall 2005-2006

• We found that total open access for Pap smears
  was causing a lot of late afternoon Pap smears to
  be scheduled.
• This left less time for the late rush of acute
  illness.
• We modified access to say no Pap smears after
  1000AM or after 200PM

See Notes
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Pap Smear Demand

• Over the last 10 years we averaged 2,500 Pap
  Smears / year. This using a variety of paradigms
  designed to maximize our ability to meet the
  demand for Paps.
• If only our female providers were doing Paps,
  and if they only did them 9 months per year, we
  would have 2500 Paps done by 5 providers in 32
  weeks.
• 2500/5500, 500/3215.6, 15.6/5
• 3.1 Paps/day/provider
• to accomplish mission.

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For advanced access to succeed, it is also
necessary to protect the doctor-patient
relationship and individual doctor's schedules.
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It's common that when doctors make
advanced-access improvements and begin to gain
capacity in their schedules, they are almost
immediately forced to absorb the overflow of
their colleagues. This creates the wrong
incentives.
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• Physicians can still cover for one another during
  absences or times of extreme demand, but the
  general rule would be for each physician to care
  exclusively for his or her own patients.

See Notes
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Special Circumstances in Open Access Systems
Planned Absences of Providers (SIU Policy)

• When a provider is planned to be absent for 1
  week or more (medical leave, vacation, etc.), the
  providers schedule will have 2 additional
  Prescheduled appointments each of the last 2
  days prior to leaving and 2 additional
  Prescheduled appointments each of the first 2
  days back at work.
• Provider group members will cover emergent needs
  labs etc. just as we already have on policy.

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Unplanned Absences of Providers(SIU Policy)

• When a provider is unexpectedly absent, attempts
  will be made to reschedule his/her prescheduled
  appointments. Patients who cannot be reached and
  patients with emergent needs will be randomly
  assigned to available staff.

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• When we launched open access, we instructed
  schedulers and physicians to verbally reinforce
  patient-physician matches each time a patient
  contacted or visited the office.
• For example, when a patient saw a physician who
  was not his or her PCP, the physician would begin
  the visit by saying, "Hello, I am Dr. Jones. I
  know you are a patient of Dr. Smith's, but I'll
  be seeing you today."
• As patients began to realize that identifying a
  PCP wasn't impeding their ability to be seen
  promptly, the number of patients volunteering the
  names of their PCPs changed dramatically.
• At one pilot clinic, the percentage of patients
  who asked for a physician by name jumped from 45
  percent to 81 percent.
• C. Dennis O'Hare, MD, MSc, and John Corlett
• Of Allina Medical Clinic
• which launched open access scheduling
• at 12 clinic sites in 1999.

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• When patients are able see their own physicians,
  their demand for additional appointments actually
  decreases by at least 5 percent.
• Moreover, when they see the same physician every
  time, patients' satisfaction and the continuity
  of care increases significantly.

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• Kaiser gradually expanded the system to all 15 of
  its adult medicine sites in northern California.
  Patient satisfaction shot up, the number of
  visits per patient dropped by an average of 7
  percent, and the regional Kaiser operation
  eliminated most of its urgent care clinics.

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Shape the Demand Reduce Demand in Primary
CareIncrease Continuity (Match Patients with
Their Primary Care Provider and Care Team)

• One of the most powerful change ideas to reduce
  demand is to promote continuity with the primary
  care provider (PCP) and the care team at all
  times. When a patient is deflected to Urgent
  Care, or even to another provider on the team,
  they may often be instructed to check back with
  their PCP, or choose to do so on their own, thus
  creating a second demand on the system. The PCP
  is in the best position to "max-pack" at that
  visit, possibly reducing future demand even
  more.  
• Practices can promote continuity by
  first committing to it. Once providers, nurses,
  and appointing staff all view continuity with the
  PCP as a priority, then scheduling  and nursing
  staff can script the appointment interaction. The
  only situations in which a patient should be
  deflected to an alternate provider or to Urgent
  Care is if the PCP is absent, or if the patient
  prefers this option because he or she cannot
  wait. Sometimes it is helpful for a mid-level
  provider to carry a smaller panel of patients,
  and be the first provider assigned to see a
  patient for a provider who is absent.  

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Example Phone Scripts

• Receptionist Which provider do you regularly
  see?
• Patient Dr Moore, but it really doesnt matter
  to me.
• Receptionist It really is better for you to
  see the same one as frequently as possible, so
  that he gets to know you better and can take
  better care of you. Dr Moore is not in today,
  but I can schedule you tomorrow with him when he
  returns.
• Patient I would rather come in today.
• Receptionist Thats fine, you can see one of
  his partners today, and next time we will try to
  get you in with Dr. Moore.

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Example Phone Scripts

• or
• Patient I would like to make an appointment
  with Dr Moore.
• Receptionist When would you like to come in?
• Patient Tomorrow sometime
• Receptionist Dr Moore is not in tomorrow. He
  could see you at 300 today, or he will be back
  in on Thursday and I could schedule you then.
• (Patient gets to choose)

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Example Phone Scripts

• or
• Patient I would like to make an appointment
  for next month with Dr Moore for my physical
• Receptionist We really try not to schedule out
  so far, since plans change and it can be hard to
  keep an appointment that is scheduled so far in
  advance. Would you like to come in sooner, or
  would you like to call back within a few days of
  when you would like to be seen? We will have
  appointments available then
• (If patient is insistent and the schedule is
  open, go ahead and schedule, but make a note for
  someone to confirm appointment the day before)

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Example Phone Scripts

• or
• Receptionist Dr Moores schedule is full today
  and we have already worked in a few emergencies.
  Since you are requesting a routine physical, I
  will need to schedule you for another day with Dr
  Moore. What day is best?
• Patient _at_(!! You people first tell
  me something about a Same Day appointment and
  have asked me to call on the same day, and now
  that I do, you tell me that I cant come in
  today! When are you going to get your _at__at_
  act together??
• Receptionist (Pleasant and smiling) We are
  doing the best that we can. We have gotten so
  busy that we have had to schedule out a few days,
  but we are working hard to get back to the same
  day appointments. Remember when you used to call
  and it took a month to get in? ? If you really
  cant wait, one of Dr Moores partners can get
  you in today, but I know that Dr Moore would
  really like to see you himself, since he knows
  all about you. He can see you at 800 tomorrow
  and you will be his first patient of the day

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Example Phone Scripts

• or
• Receptionist Dr Moores schedule is full
  today, but you can see him tomorrow morning or
  one of his partners today
• Patient I want to see Dr Moore, but I dont
  know what I am doing tomorrow. I want to call
  back tomorrow.
• Receptionist If that works better for you,
  that is fine. Try to call as early in the day as
  you can, since the schedules fill up fast and I
  cant guarantee that you will get the time that
  you want.

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Example Phone Scripts

• Remember
• Its the patients choice accommodate them
  whenever possible
• Always confirm PCP and schedule with that
  provider whenever possible.
• Try not to schedule out any further than 2 weeks,
  if possible, since the no show rate rises after
  that length of time
• Anything that you are scheduling for another day,
  try to encourage the early morning appointments.
  If the patient insists on a later time, go ahead
  and schedule (its the patients choice!)
• If the conversation is getting tense, get the
  point across to the patient that we want his
  appointment time to work for him so that he will
  be sure to make it.
• All Examples from
• Virginia Garcia
• Memorial Health Center
• Hillsboro, OR
• Via Institute for Healthcare Improvement

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Redesign the System Manage the ConstraintDrive
Unnecessary Work Away from the Constraint

• Every system has a constraint called "the
  rate-limiting step" (i.e., the step that
  determines the rate at which work passes through
  the system). This constraint usually has the most
  valuable and scarcest resources. The focus should
  be on optimizing the capacity of the
  rate-limiting step, not on optimizing every
  resource in the system. The rate-limiting step
  should never be idle, ensuring that work flows
  smoothly through it.
•  
• In a clinic setting, the primary provider is
  often the rate-limiting step because he or she
  does a number of things that uniquely add value
  to the system. Any work that the provider is
  doing that is not related specifically to his or
  her unique skills and expertise as a
  provider should be assigned to other members of
  the care team. 

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Synchronize Patient, Provider, and Information

• Start every appointment on time by asking
  patients to arrive 15 minutes before a scheduled
  appointment.
• Be sure to start every appointment on time. Agree
  on what a specific clinic appointment time means.
  If the registration desk doesnt open until 800
  AM, there is no way the patient can be placed in
  a room, have his or her history taken, and be
  ready to see the physician at 800 AM.

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• Workload For Primary Care Providers
• School Year 2004-2005
• Pts seen first semester 2004 10,967
• 8.3 Providers 17 weeks 15.54 visits/provider/day
• Begin Open Access
• Pts seen second semester 2005 10,802
• 8.2 Providers 16 weeks 16.46 visits/provider/day
• Busiest 3 weeks
• 14 Feb 4 Mar 2,424
• 19.46 visits/provider/day

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Sample Schedule Fall 2005 (Busy Day)
Double Book
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Workload For Primary Care Providers Fall 2005

• Enrollment was the same as 2004-2005
• (19,130 now, 19,125 in 2004)
• We were short one provider the first 4 weeks this
  semester, then the new provider worked at ½
  speed.
• We were running full load wide open.

• 9109 Visits to a provider
• 16 Weeks
• 569 visits per week
• 8.0 FTE providers
• 16.81 visits per provider/day

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Workload For Primary Care Providers Spring 2006

• We were short one provider for 8 weeks this
  semester.
• Our new provider was now working at full speed.

• 17 weeks
• 9934 Visits to a Primary Provider
• Effectively 7.5 providers
• When present the providers averaged
• 17.22 visits/day

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Workload For Primary Care Providers Fall 2006

• Enrollment 18,554, a drop of 570
• We were again short one provider
• First 6 weeks only
• Saw 4301 Patients
• 31 Working Days
• 7 FTEs
• 19.8 visits/day

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Sample Schedule Spring 2006 (Busy Day)
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Sample Schedule Spring 2006 (Typical Day)
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Busy Schedule Fall 2006
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Provider Hours Available Vs Patients Seen Spring
2005-Spring 2006
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Psychologic Impact on Providers

• Most of our double books occur in the afternoon.
  This is unfortunate because that is when our
  providers are getting fatigued and wishing to get
  done. Thus they often perceive a bigger problem
  than actually exists. The average number of
  double books per provider per day is 2. However
  if it's none one day and 4 the next afternoon,
  that's all the provider remembers.

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Psychologic Impact on Providers

• Seeing a schedule with lots of daylight in it
  initially, and then coming back to see all
  openings filled can be disheartening especially
  if one mistakenly spent extra time with a
  patient, thinking it was a calm day.

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Psychologic Impact on Providers

• The ideal norm for Open Access is that the
  schedule should end up just full every day.
• The average then would be for occasional days
  with a slot or 2 empty and occasional days with
  one or 2 double books.
• The world aint perfect

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No Show Rate

• First 8 Weeks of Fall Semester 2005
• 5,835 Appointments made with medical provider
• 328 No Shows for those appointments
• For a No Show rate of 5.6
• This has held to 6 or less for the last 9 months

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When The Demand for Appointments is High

• There are times when the demand for appointments
  exceeds the routine appointments available. This
  currently would seem to be caused by patients
  calling in the afternoon to be seen in the
  afternoon. (Especially if they call late in the
  afternoon.)

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Following the precepts of the Open Access
system, this is the strategy

• Offer the patient an available appointment time
  with their primary care provider (PCP)
• If the patients PCP is already fully booked for
  a given half day, the patient may well be
  amenable to an open access appointment later the
  same day or even a prescheduled appointment some
  other half day.
• Otherwise Begin double booking with the pts PCP
  
• If their PCP is getting several double bookings,
  and other providers have openings or no double
  bookings
• Offer an appointment with a different PCP
• Begin with physicians as these alternatives
  saving PAs for when Physicians get filled,
  unless there is a PA with a lot of free
  appointments.
• If everybody is booked and double booked
• Offer an appointment with the POD but advise the
  pt that there will be a wait (estimate the time)

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If none of these options are acceptable(accepta
ble to the patient)

• Advise the patient to call in the next day
• If they call early several choices of appointment
  times will probably be available
• Advise them that the times available on any given
  day may not necessarily be the time they most
  wanted to be seen.
• It is not reasonable for a patient to expect that
  they can dependably be seen at the exact time
  they had in mind, especially if they call late in
  the day.
• They can of course be offered prescheduled slots
  in the future, if they have the ability to wait
  but, again, these would be during Prescheduled
  time slots, not in Open Access slots.

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As you can see, the theme here is to do
everything possible to get the patient seen
today, and if at all possible to get them in to
their own PCP.

• We will be needing to fine tune our balance of
  prescheduled and open access slots and their
  timing in the future.
• Providers my also need to adjust their practice
  style somewhat.

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Overbusy Times

• When sudden demand over extends appointment
  availability (e.g. flu epidemics) each provider
  will be filled with his/her own patients but as
  the schedule fills providers will then be double
  booked with their own and then as necessary the
  patients of other providers. This as opposed to
  having the patients call back the next day etc.
• This should be a rare event but will cause a
  long day for everyone, when using an open access
  system. The payoff is that the crisis lasts fewer
  days, the patients are happier, and we save
  thousands in ER visits.
• In all cases nursing skills will be used
  maximally to advise those patients who really
  only need advice. However if the patient feels
  advice is not sufficient, a same day appointment
  will be offered.

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• There are many advantages of the open access
  system, including
• increased patient satisfaction and greater
  continuity of care between doctor and patient.
• There is also a resulting decrease in the demand
  for "after hours" care.
• A reduction in nurses' work load due to less time
  spent on the telephone with patients

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Internet Resources

• http//www.ihi.org
• http//www.clinicalmicrosystem.org/
• http//www.aafp.org/fpm/20000900/45same.htmlbox_b

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The End