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Service Delivery Innovation Profile

Open Scheduling and Related Strategies Lead to Zero Wait Time for Appointments and Few No Shows at Family Practice


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Snapshot

Summary

Community Physician Network Family Medicine Care–Saxony (formerly known as Olio Road Family Care), a seven-physician family practice in the suburbs of Indianapolis, ensures maximum patient access with the capability to schedule nearly any type of appointment within 24 hours through an open access scheduling system, extended hours, direct telephone access to physicians after hours, electronic visits, and other strategies. As a result, patients can get an appointment without any delay (in contrast to the typical practice where patients often must wait 30 to 60 days for an appointment), and the practice enjoys a no-show rate of only 4 percent.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on waiting time for an appointment and no-show rates, with a comparison with industry averages for waiting time. No pre- and post-implementation comparisons are available because the practice began measuring this program at its inception.
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Developing Organizations

Olio Road Family Care
Community Physician Network Family Medicine Care–Saxony is located in Fishers, IN.end do

Date First Implemented

2005

Problem Addressed

Long wait times for appointments are increasingly common and can have a negative impact on patient health and satisfaction. Given the shortage of physicians in some areas and the relatively fixed short-term nature of physician supply, reducing waiting times can be a challenging task that requires development of innovative scheduling systems and other creative strategies to serve patients more quickly with available resources.
  • An increasingly common problem: Several surveys have found that long delays in scheduling appointments are increasingly common, as outlined below:
    • A Kaiser Family Foundation survey found that more than one in four (27 percent) insured adults under the age of 65 years reported difficulty gaining timely access to a clinician.1
    • A study of adults with an urgent condition found that 43 percent were sometimes unable to receive care as soon as they wanted.2
    • A survey found that 28 percent of women in fair or poor health reported delaying care or failing to receive care because of an inability to obtain a timely physician appointment.3
    • From 1997 to 2001, the percentage of people reporting an inability to obtain a timely appointment rose from 23 to 33 percent.4
  • Delays in care a quality problem: In its landmark report Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine specified that "timeliness" is one of six key "aims for improvement" in health care.5
  • Need for creative solutions: Given physician shortages and increased patient demand, practices need to find ways to serve more patients with available resources, including new scheduling systems, more convenient hours, and telephone/electronic communication.

What They Did

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Description of the Innovative Activity

Community Physician Network Family Medicine Care–Saxony (formerly Olio Road Family Care) developed a multifaceted program that includes open access scheduling, extended hours, phone and e-mail "visits," and other strategies to enhance patient access, as outlined below:
Revised Scheduling, Hours, and Communication Options

The practice has developed a number of programs related to scheduling, hours of operation, and communication vehicles that are all designed to enhance access to care.
  • Patient portal: Patients can schedule appointments from their computer or smartphone through the patient portal. They can also access test results and medication lists, as well as requesting refills and sending e-mails to their physician. (Updated December 2013.)
  • Open access scheduling: The practice holds 50 to 60 percent of the appointment schedule open for same-day appointments. Prebooked appointments (scheduled no longer than 3 weeks in advance) account for the remainder and are typically booked in the morning, thus leaving the afternoon free to accommodate patients who contact the practice in the morning to request a same-day appointment. However, the schedule is flexible to accommodate patient desires, meaning that some open access appointments are available in the morning, and some prebooked appointments are scheduled for the afternoon.
  • Few scheduling restrictions: Front office staff members are given discretion to schedule patients as they see fit; too many restrictions complicate the scheduling process and can delay patient visits. The only guideline is length of visit: staff may schedule patients for short (15-minute) or long (30-minute) appointments. New patients, patients requiring annual physicals, and patients requiring procedures such as pelvic examinations are given long appointments, while patients requiring care for an acute problem (e.g., a sinus infection) are scheduled for a short visit.
  • Direct after-hours telephone access to physicians: A computerized answering service forwards patient telephone calls directly to the on-call physician’s cell phone, which the physician answers immediately. In most practices, patient calls are handled by an answering service, which then passes the messages along to the physicians who may take 30 to 45 minutes or longer to get back to the patient.
  • Early morning and weekend appointments: The practice offers appointments beginning at 7 a.m. to accommodate working patients (evening appointments were initially considered as well but proved to be unpredictable because patients would often be delayed by heavy traffic). The practice also offers Saturday morning appointments, handled by the on-call physician, for established patients requiring acute (rather than preventive) care.
  • E-mail encounters: The practice offers electronic visits, although the practice’s patients tend to prefer in-office visits, given the open access schedule.
  • Lunchtime phone access: The phone lines are kept open over lunch to enhance patient access.
  • Eventual online access: Eventually, the physicians would like to enhance the practice electronic medical record (EMR) with an online patient portal that will enable patients to schedule appointments and review laboratory results online. The goals of this planned enhancement are to improve the timeliness of patient receipt of information and to reduce the practice’s staffing needs.
Support Strategies
The following "support" strategies allow the practice to offer the access-enhancing services described above:
  • New patient orientation: New patients receive a 5-minute welcome orientation that outlines the practice’s scheduling process and informs patients of the need to schedule followup appointments within a 3-week time period.
  • Reminders for timely followup: The practice’s EMR generates reports that highlight needed followup care; this allows the practice to contact patients who have gaps in preventive care. The EMR also highlights gaps at the point of care so that physicians can offer needed services while the patients are in the office.
  • Ongoing patient “training”: When patients call for appointments more than 3 weeks in advance, they are reminded by front desk staff to call back the week of their desired followup appointment time. The staff also reminds patients to call the practice if they need to cancel their appointments.
  • Weekly staff–physician communication: Physicians meet on their own and with staff on a weekly basis to discuss access issues, practice operations, and outstanding issues that need improvement or resolution. In addition, physicians and the practice manager meet quarterly and with staff biannually in afternoon-long sessions that review practice goals and objectives with respect to access.
  • Smaller patient panels: Smaller-than-average patient panels—approximately 1,300 to 1,800 patients per physician—allow for greater scheduling flexibility and open appointments.
  • Quarterly improvement plan: The practice develops a quarterly process improvement plan to prompt continued service and quality enhancements; physicians and staff work together to define potential areas for improvement and implement Plan-Do-Study-Act cycles.

Context of the Innovation

Formed in 2005, Community Physician Network Family Medicine Care–Saxony has 7 physicians and 12 full-time equivalent staff (five medical assistants, one registered nurse/health coach, four front office assistants, one patient account representative, and one practice administrator). Since its inception, the practice's goal has been to make patient access a central component of care delivery. One of the founding physicians had previously practiced in a busy, rural two-physician group that was typical of many family practices: patients waited 6 to 10 weeks to see a doctor, office staff spent time calling patients to confirm appointments, and many cancellations occurred. This physician and his like-minded partners (initially one established physician and two still in residency; a fifth physician joined subsequently) wanted to build a new type of practice that would combine a small-town “feel” characterized by close patient–physician relationships, strategies that would improve access and timeliness, and technologies, such as an EMR, to enhance care quality and efficiency.
Community Physician Network Family Medicine Care–Saxony is part of the Community Health Network, which includes five hospitals in the Indianapolis area. The Community Health Network has assisted the practice in areas such as information technology and leadership. The network also introduced the practice to the Transforming Medical Care (TransforMED) project (originally derived from the Future of Family Medicine), a 24-month national demonstration project sponsored by the American Academy of Family Physicians. The goal of TransforMED is to generate new knowledge about practice transformation strategies in access and other areas.

Did It Work?

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Results

This multifaceted set of initiatives to enhance access has resulted in no wait times for patients to get appointments (i.e., they can virtually always get a same-day appointment), very low no-show rates, and steadily rising patient satisfaction.
  • Zero-days wait time: In contrast to the typical practice where patients must often wait 30 to 60 days to get an appointment, Community Physician Network Family Medicine Care–Saxony offers a same-day appointment to virtually any patient who requests one (i.e., there is no wait time for an appointment).
  • Few no-shows: Although some no-shows do occur, the practice has a very low (4 percent) no-show rate. In typical primary care practices, the no-show rate may run as high as 6 to 10 percent.
  • Patient satisfaction: Twice-a-year surveys of 200 patients from each physician show that the percentage of patients rating their satisfaction with the physician, office staff, nursing staff, and access as "excellent" has steadily increased. In the last survey, 77 percent of patients rated "wait to get an appointment time" as "excellent," and 88 percent said that they would "definitely yes" recommend this provider.
  • High levels of efficiency: The staffing ratio (i.e., the number of administrative staff for the patient panel) in the practice is low because the access-enhancing strategies prevent a backlog of patients and eliminate the need for staff to make calls to confirm patient appointments; in addition, the EMR eliminates the need for staff to spend time pulling and refiling patient charts. The current staff to full-time equivalent physician ratio is 1.93.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on waiting time for an appointment and no-show rates, with a comparison with industry averages for waiting time. No pre- and post-implementation comparisons are available because the practice began measuring this program at its inception.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Physician meetings: Because the practice was started from scratch, the physicians had the time and luxury to discuss how to organize the practice and make improvements.
  • Literature review: The physicians reviewed literature on the Toyota LEAN process, open access, and other practice management strategies.
  • Staff education: The physicians trained office staff on how and when to schedule appointments.

Resources Used and Skills Needed

  • Staffing: The initiative required no incremental staff, as everyone participates as part of their regular duties. As noted, physicians spent some time upfront reviewing the literature about open access systems.
  • Costs: There are no costs associated with the program. In fact, as noted, Community Physician Network Family Medicine Care–Saxony has fewer nonclinical staff than the typical practice due to the efficiencies created by the EMR and access-related initiatives.
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Funding Sources

Olio Road Family Care
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Adoption Considerations

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Getting Started with This Innovation

  • Reeducate staff: When personnel have worked in the same way for many years, it is difficult to change work patterns. Ongoing communication with and education of staff is required to ensure that staff members embrace new strategies.
  • Seek like-minded partners: Physicians must agree on the benefits of open access and must be willing to try new strategies. Physicians also must work well together and share a common view of the desirable practice culture.

Sustaining This Innovation

  • Meet frequently: Frequent meetings maintain a common focus on patient care goals. Ongoing communication among physicians and between physicians and staff helps to ensure ownership over the success of the practice.
  • Take care of today’s work today: If physicians fall behind on their paperwork and telephone calls, they will create a backlog of work that is hard to overcome, ultimately having a negative impact on patient access.

More Information

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Contact the Innovator

Cynthia Kizer, MD
Community Physician Network Family Medicine Care–Saxony
13121 Olio Road
Suite 300
Fishers, IN 46037
(317) 621-1300
E-mail: ckizer@ecommunity.com

Denise Gwaltney
Practice Administrator
Community Physician Network Family Medicine Care–Saxony
13121 Olio Road
Suite 300
Fishers, IN 46037
(317) 621-1300
E-mail: dgwaltney@ecommunity.com

Innovator Disclosures

Dr. Kizer and Ms. Gwaltney have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Community Physician Network Family Medicine Care–Saxony participates in the TransforMED initiative to redefine family practice. More information is available at: http://www.transformed.com/index.cfm.

Footnotes

1 Greenblatt J. Access to Urgent Medical Care, 2001. Statistical Brief No. 08. Rockville, MD: Agency for Healthcare Research and Quality; 2002. Available at: http://www.meps.ahrq.gov/mepsweb/data_files/publications/st8/stat08.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
2 Women's Health in the United States: Health Coverage and Access to Care. Menlo Park, CA: Kaiser Family Foundation; May 2002.
3 Strunk BC, Cunningham PJ. Treading water: Americans' access to needed medical care, 1997-2001. Washington, DC: Center for Studying Health System Change; March 2002. http://www.ncbi.nlm.nih.gov/pubmed/12532946.
4 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. http://www.nap.edu/html/quality_chasm/reportbrief.pdf.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 12, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 18, 2013.
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.