SummaryUsing the "advanced access model," a primary care practice revamped its appointment scheduling, tracking, and reminder processes, with the goal of enhancing access to same-day appointments. The program enhanced access to same-day appointments, reduced no-shows, and increased the provision of evidence-based care, patient satisfaction, patient volume, and revenues.Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics related to access to care, quality, patient satisfaction, and finances, with most comparisons being between 2005 (before the program was implemented) and early 2008.
Developing OrganizationsThundermist Health Center of South County
Thundermist Health Center is located in Woonsocket, RI.
Date First Implemented2005
Problem AddressedMany patients face long waits to access primary care services, with nonacute patients often waiting weeks for the next available appointment and new patients waiting even longer. The net result is frustrated patients, a dimunition in the quality of care, and excessive staff time spent triaging patients to "fit" them into limited slots available in the day's schedule.1 Poor planning and systems are frequently responsible for these long waiting times. In addition, inadequate reminder systems and long in-office waits can lead to high no-show rates; as a result, many practices "overbook" patients, which often proves to be counterproductive.
- A common problem: Wait times for appointments vary dramatically by region and by provider. One survey of 250,000 Kaiser Permanente patients served by 100 primary care physicians (PCP) in northern California found the average wait for an appointment was 55 days, and the likelihood that patients were able to see their personal physician was less than 47 percent.2
- Lack of timely appointments hurts health care quality: The inability to obtain timely appointments not only frustrates patients, but may lead to poor quality of care. One population-based study in Virginia found that delays in obtaining timely primary care appointments were associated with lower immunization rates.3
- Poor planning a common cause of delays: Although delays in securing appointments are commonly considered to be an inevitable result of resource limitations, they more commonly stem from poor planning and irrational scheduling and resource allocation. Application of queuing theory and principles of industrial engineering, adapted appropriately to clinical settings, can reduce delays substantially, even in small practices, without requiring additional resources. Although these principles are powerful, they are counter to deeply held beliefs and established practices in many health care organizations.4
- No-shows an added complication: Inadequate reminder systems and long in-office waits contribute to high no-show rates in many primary care practices. To compensate for no-show patients, many practices "overbook" patients, which may be counterproductive (leading to even longer in-office waiting times). Research shows that patients who feel disrespected by being forced to wait a long time in the waiting room feel no obligation to show up for appointments, or even cancel them ahead of time.5
- Increasing problems at Thundermist: In 2004, Thundermist Health Center of South County in Rhode Island had a patient no-show rate of more than 22 percent. To meet budget projections and offset the no-show rate, patients were often double-booked. In addition, nurses spent significant time screening calls to determine if patients were sick enough to qualify for one of the few available same-day appointments (only 30 percent of slots were set aside for same-day appointments). The net result was a "downward" spiral, with increasing levels of patient dissatisfaction leading to even more no-shows, and increasing levels of staff dissatisfaction due to unpredictable and erratic patient scheduling.6
Description of the Innovative ActivityUsing a model known as the "advanced access model of care," the primary care practice revamped patient flow, scheduling, and follow up processes to facilitate access to same-day appointments for as many patients as possible. Highlights of the process improvements include the following:
- New appointment lengths and scheduling guidelines: The duration and types of available appointments were simplified. Although the practice traditionally offered five different appointment types, there are three under the revised system: a 15-minute revisit for existing patients; a 30-minute appointment for physicals; and a 30-minute appointment for in-depth diagnostic procedures. Telephone triage guidelines were developed to allow receptionists to match patients with the appropriate type of appointment. Whenever possible, staff tried to consolidate all needed tests and services into one appointment. In addition, the practice began sending out letters to patients with routine laboratory results rather than having them come in for follow up visits to receive the results. Handouts are provided to patients explaining how the new system works.
- Provider and office staff support: The practice developed systems and tools to help providers and office staff facilitate appointment scheduling. For example, the provider encounter forms were changed to provide space to designate a patient's follow up needs. In addition, patient reminder postcards and a "chart prep" form were developed that provide information on appropriate scheduling and followup protocols. Regular staff meetings are held to discuss the system, share data, and obtain feedback for improvement.
- Revamping of panel size: The size of each physician's and nurse practitioner's patient panel was reviewed and reapportioned to increase the chance that a patient can see his or her preferred provider. See the Planning and Development section for more details on this process.
- Patient reminder and recall system: The practice began using a scheduling software program that prompts the provider to enter follow up directions when seeing a patient. The checkout staff review the follow up directions with the patient and encourage the patient to call and book the appointment within the 72-hour window before it should occur. (Analysis showed that no-show rates were higher if patients booked too far in advance). The system also automatically generates a list of patients who are due to make an appointment during this window, and office staff call these patients to try and schedule one. A letter is sent if the patient cannot be reached by phone. Every attempt is made to meet individual patient demands, including accommodating transportation and work schedules.
- Ongoing monitoring and evaluation: The advanced access team, consisting of a receptionist, medical assistant, provider, director of practice management, site director, and senior practice leader, regularly monitor results. A one-page weekly tracking tool monitors the number of available appointments, scheduled appointments, patients who call but cannot get a same-day appointment, canceled appointments, no-shows, prebooked appointments, visits per hour by provider, and relative value units per provider. The tool also tracks gross revenue by provider versus budget. On a monthly basis, the practice tracks patient satisfaction, with particular attention being paid to the ability to get an appointment, prompt return of phone calls, and time in the waiting room. On a quarterly basis, the practice evaluates the number of new patients. The practice also periodically conducts "spot checks" of the reminder system.
References/Related ArticlesBundy D, Randolph G, Murray M, et al. Open access in primary care: results of a North Carolina pilot project. Pediatrics. 2005;116(1):82-7. [PubMed] Available at: http://pediatrics.aappublications.org/cgi/content/full/116/1/82
Valenti W, Brookhardt-Murray L. Advanced-access scheduling boosts quality, productivity and revenue. 2004. Available at: http://www.ihi.org/knowledge/Pages/Publications/AdvancedAccessSchedulingBoostsQuality.aspx
Randolph GD, Murray M, Swanson JA, et al. Behind schedule: improving access to care for children one practice at a time. Pediatrics. 2004;113(3):e230-7. [PubMed] Available at: http://www.pediatrics.org/cgi/content/full/113/3/e230
ResultsA pre- and post-implementation comparison shows that the revised scheduling and reminder systems enhanced access to same-day appointments, reduced no-shows, and increased provision of evidence-based care, patient satisfaction, patient volume, and revenues.
Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics related to access to care, quality, patient satisfaction, and finances, with most comparisons being between 2005 (before the program was implemented) and early 2008.
- More same-day appointments: The percentage of patients able to get same-day appointments rose from 60 percent in late 2005 to 95 percent in July 2006.
- Fewer no-shows: The number of patients who failed to show up for appointments declined from 21 to 10 percent of total appointments.
- Greater adherence to evidence-based care: The percentage of diabetic patients who had their hemoglobin A1c (average blood sugar level) tested at least twice in the past year climbed from 53.8 percent in 2005 to 59.6 percent in early 2008, while the percentage receiving annual foot examinations rose from 68.8 to 75.8 percent over the same time period. The percentage of eligible patients who received a flu vaccine in the past year climbed from 40.4 to 51.7 percent, with corresponding figures for pneumococcal vaccines rising from 71.6 to 74.7 percent.
- Improved outcomes: Hemoglobin A1c levels in diabetic patients declined from 7.9 to 7.6 percent between 2005 and early 2008. (The ideal rate is 7 percent.)
- Increased patient volume and revenues: The number of new patients seen in the practice rose by 4 percent. Gross revenues as a percentage of budgeted revenues rose from 85 to 96 percent. Although total patient visits fell by 1 percent (due to consolidating multiple services into single visits and eliminating follow up visits to share routine test results), relative value units—the amount of physician time, resources, and expertise needed to provide various services to patients—rose by 4 percent.
- More satisfied patients: Satisfaction scores increased by 17 percentage points, from 83 to 100 percent, with 93 percent of patients indicating satisfaction with the prompt return of phone calls (a 2-percentage point increase). In addition, 83 percent of patients were tracked in the patient recall system, and 79 percent were able to obtain an appointment with the provider of their choice.
Context of the InnovationThundermist Health Center of South County is one of three community health center sites operated by the nonprofit Thundermist Health Center. Thundermist is a Federally Qualified Health Center serving approximately 1,200 patients monthly. The practice, which provides care to a mix of uninsured and privately and publicly insured patients, employs two physicians, two nurse practitioners, three registered nurses, and administrative staff. The practice had historically struggled with scheduling, with nearly one-third of patients either failing to show up or rescheduling at the last minute. The clinicians convinced Thundermist management to try the advanced access model. Management agreed on the condition that the initiative would be budget-neutral and improve patient satisfaction. Advanced access, also known as open access or same-day scheduling or open access, is a scheduling system based on the principle that patient demand for appointments is predictable and most patients should be able to attain same-day appointments with their providers. It is not the same as a walk-in clinic, because patients still receive an appointment for a specific time, and they receive notification when they are to call and schedule an appointment in the future. In 2005, Thundermist began working with Quality Partners, Rhode Island's quality improvement organization, to implement the model. At the time it was implemented, the practice did not have an electronic medical record but did use scheduling software.
Planning and Development ProcessThe key steps in the planning and development process primarily have to do with analyzing current practices to understand problems and issues that need to be addressed:
- Understanding and revising PCP panel size: One of the first issues addressed was panel size—the number of patients for whom a provider or care team is responsible for, usually measured by number of visits per week. In this practice, patients were not consistently assigned to a PCP, and, therefore, the practice lacked an accurate understanding of how many patients each provider treated each week. To address this issue, an analysis was conducted showing patient age, dates seen, and by whom, and then a PCP was assigned based on who saw the patient most frequently. Provider patient panels were then recalculated based on actuary tables adjusted for patient age and compared with Institute for Healthcare Improvement standards.
- Understanding supply and demand: The practice conducted daily appointment demand studies for a period of time. Each study evaluated booked appointments (both new patients and followups) and walk-ins for the day. Data were plotted against the number of available provider appointments that day and the number of patients actually seen. This analysis showed there was sufficient weekly provider capacity, but that some adjustments were needed in how provider hours were scheduled during the day.
- Understanding no-show appointments: An analysis was conducted of patients who failed to keep appointments. This analysis showed that patient no-shows increased if the appointment was booked more than 72 hours before the appointment, which led to the decision to encourage patients to schedule within this window.
- Understanding calls for appointments: Initially, there were five different kinds of appointments, with staff following directions for when and how to book each type of appointment. An analysis was made of these telephone calls, including which calls went to the nurse, the reason for calling, and how long it took for the nurse to return the phone call.
- Understanding what happened after a patient was seen: An analysis showed that roughly 30 percent of patients were booked immediately for follow up appointments. If patients did not have a follow up appointment, there were few systems in place to reconnect with them, resulting in the practice losing track of many of these patients.
- Training: The clinic sent a team to external training sessions on the advanced access model, and also held periodic in-house training until staff became comfortable with the new system.
- Revamping the information technology system: The practice information technology system was revamped to integrate patient reminder tools and mirror the new practices. For example, the documentation system was expanded to produce patient flyers, reminder postcards, chart preps, encounter forms, and weekly tracking tools.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, although administrative time is needed to track and report on data, and staff time is required to participate in training sessions and regularly scheduled planning meetings.
- Software and equipment: The practice upgrades its scheduling software.
- Costs: The primary costs consist of staff time for meetings, training, and data analysis, and those expenses related to producing patient handouts, reminder and follow up cards, and new prep charts and encounter forms. Would-be adopters might also need to purchase tracking software to enable immediate analysis of patient flows. At Thundermist, incremental costs were more than made up for by the revenue increases that accrued from the program's ability to free up capacity to serve new patients and provide more services.
Funding SourcesThundermist Health Center
Getting Started with This Innovation
- Appoint a champion and implementation project team with representatives from every part of the practice that has an impact on patient flow and scheduling.
- Find a state or regional quality improvement organization that can provide support during the implementation process. Two or more practices can contract jointly with a consultant or other organization to achieve economic efficiency.
- Conduct an analysis of the office system, including panel size, provider capacity, and patient demand.
- Identify the process improvements needed to transition to same-day scheduling, including redeployment of staff, modification of medical records and patient scheduling systems, and creation of new appointment types and guidelines for reception staff who handle triage telephone calls.
- Review and upgrade patient encounter forms, and make sure there is a seamless interaction between followup instructions and the scheduling and reminder systems.
Sustaining This Innovation
- Develop systems and tools for regularly monitoring key metrics related to scheduling, patient satisfaction, and revenues.
- Make special efforts to educate patients (especially new ones) on the need to call for follow up appointments during the 72-hour window before the visit should occur. Many patients would rather book ahead (at their initial visit), but this practice leads to high no-show rates. Over time, patients will learn to trust that appointments will be available when they call, but generating this trust takes time, particularly with new patients.
Use By Other Organizations
- The Fairport Internal Medicine Group in western New York is one of several practices that have implemented the advanced access model.
6 Thundermist Health Center of South County. Working report on Open Access model of care integration. Woonsocket, RI. 2007.
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Service Delivery Innovation Profile
Original publication: May 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 24, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 16, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.