Appendix A

Background Papers

OPEN ACCESS OR ADVANCED ACCESS SCHEDULING

Mark Murray, M.D., M.P.A. Mark Murray & Associates, LLC

Primary care services form the core of the ambulatory health care system, are in high demand, and are characterized by the most prolonged waits. Access to robust primary care also lies at the heart of effective delivery system reforms, such as with the formation of accountable care organizations (ACOs) and patient-centered medical homes. Current attempts to triage health care appointments based on anticipated patient acuity are unreliable, costly, and operationally difficult. Preferable is the presumption of same-day response to requests, with patient preference serving as the key determinant of the actual timing and nature of care or provision of alternative arrangements. Presented below is one successful method to provide same- or next-day appointments. Although presented in sequence, many of the steps will overlap in practice. Active involvement of patients and their families is an integral part of the design, implementation, and evaluation of this plan.

Actions in Phase One: Past and Prospective Data Collection

Current visit rate = total number patient visits in the last year ÷ total number of patients

Demand = the number of appointments generated on any given day. This includes appointments made ON today FOR today and appointments made ON today FOR any day in the future.

* If demand is counted only as appointments seen on any given day, it would only equal the number of appointments on the schedule. The demand calculation could then potentially miss any appointments that could not be accommodated and were therefore pushed out to a future day.

Supply (Capacity) = (the number of appointment slots per day for each clinician in a practice) × (the days of work per week by the clinician)

Activity = the daily number of patients who arrive and receive care from a provider

Panel size = the number of patients seen by a physician in the past 12 months

1. Patients who have seen only one provider for all visits are assigned to that provider.
2. Patients who have seen more than one provider are assigned to the provider they have seen most often.
3. The remaining patients who have seen multiple providers the same number of times are assigned to the provider who performed their most recent physical or health check.

Backlog = appointments booked for future dates = previous demand showing as work to be completed in the future.

Actions in Phase Two: Balancing Demand and Capacity

• Determine panel size for the practice and for each provider within the practice, and calculate the unique unduplicated patients seen in the last year. The panel sizes for each provider may be different.
• Determine the practice visit rate using the practice average as well as the individual visit rates. Recognize that the patient visit rate includes visits to the patients’ preferred provider in addition to visits to someone else in the practice.
• Develop a spreadsheet that compares demand to capacity at both the practice and individual practitioner level.
• If the practice balances but the individuals do not, develop a plan to achieve balance by an immediate transfer of patients or a gradual change of patients through natural attrition. The goal is for each provider to be slightly underpaneled to provide some surge capacity and slack.
• If providers are overpaneled (too many patients per provider), use strategies to reduce demand and improve capacity enhancement to achieve a balance before addressing any backlog.
• Start to measure and record daily demand, capacity, and activity.
• Monitor panel size monthly.
• Determine the current third next available appointment (TNA) for the practice and each provider. In the case of an extended TNA, develop a backlog reduction plan.
• Book future appointments for 3 to 4 months in advance only and do not hide demand within a waiting list.
• After initial review of patient panels, restrict the responsibility for shifting patients from one provider to another to a single individual (a “broker”), and keep track of the reasons for change.

Actions in Phase Three: Addressing Backlog

• Measure extent of backlog. This can be done by TNA or by counting the number of prebooked appointments on the schedule. Some of these patients are appropriately prescheduled in the future due to physiology. The backlog is not as bad as count.
• Set a date to start backlog reduction and an expected end date. The end date will be the start date for the new advanced access schedule

• template. Backlog reduction is “everybody work,” not just provider work—staying late involves everyone.

• Add capacity in the form of more visits per day in order to stop the delay from accumulating and to catch up to the delay.
• During backlog reduction, there will be three queues:

— A queue for the currently prebooked appointments for the day,

— A queue for urgent/same-day appointments, and

— A queue for patients booked into the future, backlog appointments.

• Initially, the urgent slots will fill early and most of the backlog slots will be urgent. With progress toward eliminating the backlog, gradually loosen the criteria for who gets into the backlog slots. At the end of backlog, as evidenced by a significant reduction in TNA, the backlog slots will be filled by traditional types of appointments.
• Once the backlog is gone, eliminate both the urgent slots and the backlog slots and commit to finishing all the work each day.

Actions in Phase Four: Using the New Scheduling Template

• The goal is to see patients on the day they call the office and not schedule the majority of visits into the future.
• Build the new schedule template with a single appointment type, which will involve a significant workflow change. Instead of appointing new patients to the first open slot on any schedule, schedulers will look for the specific designated provider and appoint to that provider.
• Once there is no daily backlog, as evidenced by open slots each day, continue to measure the TNA for the single appointment type.
• Schedule return patients back late in the week and early in the day, when demand is usually lowest. This is load leveling.
• When scheduling return appointments, it is essential to look at the entire schedule to avoid overbooking of any particular day in the future. The goal is to spread out demand from patients who choose a day other than today with prescheduled return visits in order to preserve enough time for expected daily demand.
• Develop contingency plans:

— Plan for post-vacation and out-of-office recovery. Make a plan for equitable coverage of patients from the absent providers.

— Develop a plan to manage the end of the day, particularly when the schedule is “full.”

— Develop a safety-recovery plan to determine if a patient needs to be seen immediately. In the absence of urgency, all patients are offered an appointment today. Most are appointed today. Some may be

seen immediately. Patients who choose to wait are appointed onto the future schedule.

• Use a care team workload analysis for the entire practice to drive unnecessary work away from providers.
• Demand reduction strategies can help balance an unbalanced equation or can serve to open capacity for new patients entering the practice when supply and demand are balanced. Examples of demand reduction strategies include:

— Committing to continuity to reduce “system churn”

— Doing more with each visit

— Extending visit internals

— Using the telephone as a means for follow-up

— Expanding the use of staff for some appointment work

— Scheduling group visits when appropriate

• Distribute the new patient work only to underpaneled providers. Monitor the over-under panel monthly, and open or close providers to new patients either monthly or weekly.
• Once the practice is in a steady state, new patients are accepted at the same rate that patients graduate from the practice.
• Create a flow map of the patient journey at the encounter, and identify delays between steps. Use office efficiency strategies to improve the flow of work.

REENGINEERING FLOW THROUGH THE PRIMARY CARE OFFICE

Eugene Litvak, Ph.D. Institute for Healthcare Optimization

The balance of providing timely appointments to patients who need and want them while maintaining a smoothly running practice can be a challenge. Transition is often best accomplished in phases and involves the active participation of all those affected by the change, including patients and families. The following represents one three-phased approach. Phase one focuses on balancing resources and flow of patients with time-sensitive medical complaints with those with elective or scheduled appointments. The main goals of this phase are to improve patient access for those with time-sensitive needs (same-day access and walk-ins) and to decrease the operational chaos that results from competing demands for appointments. The second phase turns attention to the challenge of smoothing elective or scheduled patient flow, such as appointments for yearly physicals, immunizations, or blood pressure checks. The main goals of this phase are to maintain continuity with a specific provider to maximize the quality of care, decrease competition between scheduled and unscheduled appointments, and to enhance office throughput of patients. The third phase aims to optimize capacity in the office to improve quality, safety, and throughput. Using alternative ways of addressing patient concerns, alternative settings of care, and alternative providers when needed creates the opportunity to correct the size of the appointment type and number to better match capacity with demand.

Actions in Phase I

• Separate patients into homogenous groups (i.e., same-day access or walk-ins versus scheduled flows, new patients versus return patients). or
• Develop and implement a physician-driven urgency classification system for triage based on key patient symptoms.
• Prospectively collect 3 months of data based on the above classification system to accurately determine case mix in terms of urgency.
• Calculate how many appointment slots are needed based on past statistics and staff accordingly.
• Develop and establish standard operating procedures and processes to appropriately accommodate unscheduled and scheduled patients.
• Reduce waiting times for same-day or walk-ins, increase throughput, and decrease overtime for staff by evaluating patient flow through clinic and the involved processes that provide roadblocks.

• Walk-ins and same-days may not always get to see their own doctor. Continuity is not a problem—another set of eyes may be good.
• Implement redesign, and monitor patient flow performance.

Actions in Phase II

• Prospectively collect 3 months of data based on the above classification system to accurately determine case mix in terms of urgency.
• Track cancellations and no-shows.
• Develop a cancellation policy for scheduled appointments and no-shows. Options include

— Overbooking patient appointments if the number is less than 10 percent. If for a particular weekday, statistics for a single provider reveal that there are two no-shows, then on average, two patients can be overbooked without any risk of overtime.

— Allow additional overbooking if providers agree to work until all patients are seen.

• Smooth the flow of scheduled patients to decrease the competition from unscheduled office arrival, such as walk-ins and same-day appointments, maximizing the throughput to decrease wait times.

— Analyze drivers of variability, and identify necessary scheduling changes to achieve schedule smoothing.

— Increase officewide throughput to achieve consistent nurse-to-patient staffing.

— Increase patient placement in appropriate areas within the clinic, such as in registration, lab, office, and checkout.

• Phone call data can be used as a means to improve throughput.

— Determine the distribution of calls for each day and hour of the day.

— Determine the drivers of call variability.

— Develop office strategy and resources for answering phone calls to minimize the loss of potential patients.

Actions in Phase III

• Once scheduled demand is smoothed, determine the number of appointment slots needed for same-day, walk-ins, and prescheduled patients.
• Evaluate the role of artificial variability in flow and scheduling bottlenecks to minimize the influence of provider and staff preference on throughput.
• Estimate resources (e.g., providers, staff, rooms, shared equipment) needed for each type of flow to ensure right care.

— Determine alternative ways of addressing patient concerns (phone call, e-mail, smart phone data, etc.).

— Consider alternative settings of care (group visits, virtual clinician, mobile health unit, etc.).

— Develop alternative providers when needed (office staff for prescription refills, postdischarge follow-up by nurses, scheduler-led triage, managers for billing and insurance triage, etc.).

— If the number of nonclinical calls is negligible, an ad hoc method to address them could be adequate; however, if the number of these calls is significant, carve out a resource with a defined role to provide nonclinical intervention.

• Prospectively collect data based on the above criteria to accurately determine demand.
• Review office capacity scenarios using data, and make necessary changes to better match capacity to demand.

REENGINEERING FLOW THROUGH THE ACUTE CARE DELIVERY SYSTEM

Eugene Litvak, Ph.D. Institute for Healthcare Optimization

Coordinating the function of the operating room and inpatient units is one of the most challenging tasks in health system reengineering and is perhaps best tackled in stages. Key to the successful design, implementation, and evaluation of these plans is the active participation of patients and families. The following represents one three-phase approach. Phase one focuses on balancing resources and flow of time-sensitive emergent/urgent with elective/scheduled admissions (mostly surgical). The main goals of this phase are to improve patient access and decrease daily operational chaos that results from competing demands. The second phase turns attention to the challenge of smoothing elective/scheduled patient flow (e.g., surgical, catheterization lab, or radiology procedure) to inpatient units. The main goals of this phase are to improve quality and safety of care on corresponding units, decrease competition between scheduled and unscheduled flow on inpatient units, and to enhance elective surgical or medical throughput (or both) depending on the hospital’s priorities. The third phase aims to correctly size inpatient units to improve quality, safety, and throughput to alleviate medical ward bottlenecks that can feed back to the operating room. This phase addresses artificial variability in admissions, discharges, and transfers and improves throughput in selected medicine units by ensuring appropriate patient placement and improving the timeliness of admissions, discharges, and transfers out. In doing so, it also creates the opportunity to correctly size medical wards to better match capacity with demand.

Actions in Phase I

• Develop and implement a surgeon-driven urgency classification system that will determine the maximum acceptable wait time for each surgical case.
• Prospectively collect 3 months of data based on the above classification system to accurately determine case mix in terms of urgency.
• Develop and establish standard operating procedures to appropriately accommodate unscheduled and scheduled flows.
• Evaluate and choose from redesign models based on data.
• Implement redesign, and monitor patient flow performance.

Expected Outcomes in Phase I

• Increased surgical throughput.
• Decreased operating room overtime.

• Decreased wait time for urgent/emergent surgeries, and improved compliance with desired maximal acceptable wait times.
• Decreased hospital acute length of stay for urgent/emergent patients
• Improved outcomes for urgent/emergent surgical patients.
• Enabled further operating room efficiency improvement such as on-time starts, lower turnover time, and high-performance teams for elective blocks.
• Improved patient satisfaction relating to decreased elective case delays.
• Improved staff satisfaction and retention.

Actions in Phase II

• Accurately determine your truly elective inpatient admission volume for the selected service(s).
• Collect prospective data if needed.
• Analyze drivers of variability, and identify necessary scheduling changes to achieve schedule smoothing.
• Assess and realign weekend resources as needed.
• Evaluate and choose from redesign models based on collected data.
• Implement smoothing redesign, and monitor patient flow performance.

Expected Outcomes in Phase II

• Increased throughput in smoothed inpatient unit.
• Increased placement of patients in the optimal units with decreased postanesthesia care unit boarding and interunit transfers.
• Higher reliability in nurse-to-patient staffing level leading to lower morbidity and mortality.
• Improved staff satisfaction and decreased use of nursing overtime.
• Quality improvement in terms of decreased readmissions, decreased use of rapid response teams, decreased rate of hospital-acquired infections, and patient safety issues.

Actions in Phase III

• Develop and implement patient-centered admission, discharge, and transfer criteria that will determine what clinical characteristics are necessary for admission to and discharge from the selected unit(s).
• Implement admission, discharge, and transfer criteria; monitor adherence to criteria as well as patient flow performance.
• Prospectively collect data based on the above criteria to accurately determine demand and clinically appropriate length of stay for the selected unit(s).

• Review bed capacity scenarios using data, and make necessary changes to better match capacity to demand.

Expected Outcomes in Phase III

• Increased placement of patients in the optimal units.
• Decreased waits and emergency department boarding.
• Decreased interunit transfers.
• Improved emergency department and inpatient unit staff satisfaction.
• Potential decrease in acute length of stays.
• Quality improvement with decreased readmissions, decreased use of rapid response teams, decreased rate of hospital-acquired infections, and increased patient safety.

FRAMEWORK FOR ACTIVE PATIENT INVOLVEMENT IN ACCESS AND SCHEDULING

James B. Conway, M.S. Harvard School of Public Health

Core Principles of Patient- and Family-Centered Care

• Dignity and respect: Providers listen and honor patient and family perspectives and choices.
• Information sharing: Providers share complete and unbiased information in ways that are affirming and useful.
• Patient and providers equally participate in care and decision making.
• Patients and providers equally collaborate in policy and program development, implementation, and evaluation, as well as the delivery of care (IPFCC, 2010).

Tenets of a Patient- and Family-Centered Access and Scheduling System

• Patients are the source of control (IOM, 2001).
• Access is defined from the patient perspective.

— I get information and services that meet my needs, not just a visit, by using a wide range of asynchronous approaches—smart phone apps, e-visits, my home or workplace, and online scheduling.

— I have access to the right people to match my needs, not just to physicians, but to community health workers, lay care coordinators, interdisciplinary teams, and pharmacists.

• Right care, right place, right time, every time.

— “I get the care and information I want and need when, where, and how I want and need it”—Donald Berwick, IOM Engineering Optimal Health Care Scheduling: A Public Workshop (2014).

• Waits can contribute to the burden of illness.
• All health systems set the goal of offering an appointment on the day and time the patient choses.
• The system meets the patient where they are:

— By expanding hours worked per day and number of days worked per week;

— By addressing cultural and technological competency;

— By including navigation assistance whenever needed; and

— By remembering that, for many patients and family members, engagement is therapeutic.

• All health systems set goals of increasing access, supporting care continuum, and reducing time to next appointment.

• As part of future models, the team comes collectively to the patient as opposed to the patient seeking out multiple individuals.
• Engagement is not just looking good but doing good.

Hypothetical Model of Application

1. Questions arise around health and health care:

— Patient, family, and staff seek counsel when new questions arise or new information is needed.

— The system for moving forward is understood by all.

2. Collaborative processes are implemented to move forward and to get answers:

— Focus first and foremost on meeting the needs of the patient: providing the right care, at the right place and the right time, every time.

— Use a wide range of asynchronous approaches.

— Ensure access to the right people to match needs.

— Engage patient and family members in full partnership, with questions prompted, invited, answered, and understood by all.

— Make a consultant immediately available.

3. Scheduling test, treatment, consult, and so on:

— Ensure an efficient processes: one person, one call, one time.

— Offer a wide range of approaches, such as scheduling online, in person, or over the phone, with navigation and other assistance, such as language and access support, when needed.

— Determine what works best for the patient and family.

— Seek out and address any special needs and requirements.

— Prepare in advance, and provide fact sheets.

4. In the interval: focus on questions and preparations:

— Ensure immediate access to a person 24/7.

— Solicit and answer questions.

— Distribute and follow through on preparations.

— Provide directions.

— Provide preappointment notifications.

5. Once the appointment is held:

— Update administrative needs and medication.

— Ensure that all parties are on time (patient, family, and staff), or are informed if not.

— Deliver care in appropriate and respectful setting.

— All parties prepare questions, listen, and respond.

— Patient choses who is with them.

— Document in electronic health record (EHR) system.

— Next visit follow-up before leaving.

6. Follow-up actions taken:

— Results and follow-up actions are communicated to patient and family members in real time in person, via end-of-visit note, and in patient portal.

— Results are communicated to care team in real time.

— Patient and family members are engaged in any revision to care plan.

7. Ongoing care is provided with care team (patient, family, and all staff).

Patient and Family Collaboration in Design and Continuous Improvement of Access and Scheduling Systems

• Overarching principle: Patients and family members collaborate in policy and program development, implementation, and evaluation, as well as in the delivery of care (IOM, 2011).
• Application: This principle is applied in the individual experience of care, in microsystems, in organizations and systems, and in the community.
• Specific to access and scheduling:

— Design/re-design: Any time groups meet to design or redesign access to and scheduling of care, patients and family representatives are full members of the design team from the beginning through the end of the process.

— Continuous improvement: The voice of the patient and family is sought as a key collaborator in improvement.

— Construct design: Embracing application of the findings on high reliability and mindfulness is a helpful illustration (Weick and Sutcliffe, 2001).

— Transparency of real-time performance is the goal.

— Improvement practice is grounded in high-reliability principles of mindfulness as explained in Table A-1.

TABLE A-1 Application of Mindfulness to Patient- and Family- (P&F-) Centered Access and Scheduling

REFERENCES

IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

IOM. 2011. Patients charting the course: Citizen engagement and the learning health system: Workshop summary. Washington, DC: The National Academies Press.

IPFCC (Institute for Patient- and Family-Centered Care). 2010. What are the core concepts of patient- and family-centered care? http://www.ipfcc.org/faq.html (accessed November 3, 2014).

Weick, K. E., and K. M. Sutcliffe. 2001. Managing the unexpected: Assuring high performance in an age of complexity. Hoboken, NJ: Wiley.

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