Problem Addressed

• 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.

Description of the Innovative Activity

• 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.

• 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.

References/Related Articles

Contact the Innovator

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

Innovator Disclosures

Results

• Zero-days wait time: In contrast to the typical practice where patients must often wait 30 to 60 days to get an appointment, Olio Road Family Care 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?)

Context of the Innovation

Planning and Development Process

• 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, Olio Road Family Care has fewer nonclinical staff than the typical practice due to the efficiencies created by the EMR and access-related initiatives.

Funding Sources

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.