Open Access Scheduling. PAFP/IPIP CES Residency Program Collaborative LS4 June 10, 2011 King of Prussia, PA George Valko, M.D.

Transcription

1 PAFP/IPIP CES Residency Program Collaborative LS4 June 10, 2011 King of Prussia, PA George Valko, M.D.

2 DISCLOSURE Neither I nor any immediate family member (parent, sibling, spouse or child) has a financial relationship with or interest in any commercial entity that may have a direct interest in the subject matter of this session.

3 Agenda What is Open Access? Why do Open Access? Implementation Overview Data Pitfalls and Caveats

4 What is it? An advanced/open access system is one where capacity and demand are in equilibrium on a daily basis Enables patients to be seen when they want to be seen No queues. Few rules Eliminate distinction between urgent and routine care Hidden capacity is discovered Work is done at the end of the day

5 Why Do It? Reality: For years, the hallmark of a successful practice has been appointments that have been booked months in advance. If a patient missed (or cancelled) an appointment or the clinician cancelled office hours, that patient would have to wait weeks or months for another appointment. For patients who are ill or for other reasons need to he seen urgently, the wait is less but usually at the expense of other patients appointments or the clinicians time, i.e., they are squeezed into an already busy schedule. To try to maintain a full schedule, office staff would double- and triple-book appointment slots in anticipation that a certain percentage of patients would cancel or not keep their appointment

6 Why Do It? Potential Benefits: The primary benefits of open access scheduling accrue to both the patient and the physician; patients are afforded greater ease in obtaining appointments and physicians enjoy increased productivity Improved patient satisfaction as a result of receiving sameday appointments Improved timeliness of patient care, (including accommodating the patients of colleagues who are out of the office) Increased number of patients who arrive for a scheduled visit, largely due to increased availability Decreased patient no-shows and cancellations Decreased physician cancellations Improved office efficiency due to reduced need to reschedule patients Improved bottom line resulting from full schedules.

7 Components Understanding profile of demand Adjusting the handling of demand Matching capacity to demand Contingency plans Communication Fewer appointment types Maximize visit

8 Implementation What is needed: Strong leadership Buy in from Faculty, Residents and Staff but emphasize this is mandatory Education: Change itself Fear - no patients will show My patients are different Elderly Transportation issues Planning (but not too much)

9 Implementation Challenges in Academic/Residency Program FTE status due to other multiple jobs

10 Implementation First: Set Goals: To see any and all practice patients whenever they want or need to be seen, or To have a patient seen by their own clinician

11 Implementation How much open access is right for the practice? Usually 100% open access is not practical A more mature open access, sometimes referred to as advanced access is based on good backlog, in which a percentage of future appointments are made for specific reasons. Such reasons include: Clinician s need to see a patient on a certain date (for example, a BP check for change in meds or suture removal) Patients desire to have an appointment on a certain date because of transportation issues This is in keeping with the tenet to see each patient when they want or need to be seen

12 Implementation, Cont d Visit Types New Physical (30 minutes) New Sick (15 minutes) Established (15 minutes) Team Approach -- Schedule clinician>team>carenow

13 Measure! Improvement in (?): Patient arrival, no-show, bumps Continuity

14 Implementation JDFCM Experience: Started July, 2002 No work down of backlog Mandatory for all physicians Worsening financial situation High Anxiety

15 Implementation Start - 50% Prescheduled, 50% Open Access 3 Months - 25% Prescheduled, 75% Open Access 1 Year - 20% Prescheduled (traditionally scheduled) 20% One week in advance (advanced access) 60% Open Access (1 business day in advance) Own patients scheduled 8-10AM, and for the weekly and traditionally scheduled times Double-books added on

16 Patient Statistics, Academic Year : Bumped Cancel No Shows Arrived Attendings 6% 17% 19% 57% Residents 5% 16% 24% 54% Practice Total 5% 16% 19% 60% SDA 0% 6% 8% 85%

17 First Month Open Access Scheduling Results Patient numbers increase (biggest July ever) Decreased physician hours Stats: No Show Arrived Attendings 14% (19%) 67% (57%) Residents 20% (24%) 65% (54%) Practice 15% (19%) 66% (60%) Total Charges Increased Physician Anxiety Decreased

18 Results, cont d Third year ( through March, 06) 84,650 patients scheduled Bumped Cancelled No Show Arrived Attendings 4%(6) 17%(17) 13%(19) 65%(57) Residents 3%(5) 19%(16) 19%(24) 59%(54) Practice Total 3%(5) 18%(16) 16%(19) 63%(60)

19 Continuity of Care Barriers to Continuity of Care in an Academic Medical Center: Variability of resident rotations results in disability to match resident supply with patient demand Work hour rules Variability of learners from PGY 1-3 These can be fixed

20 Continuity of Care Results: Residents Number of Number of Number of Responders Sessions TPS % Mine 80/

21 Continuity of Care Results: Faculty Number of Number of Responders TPS % Mine

22 Complaints Physicians Too Busy Phone Lottery Own Patients Patients Phone Lottery/phone waiting times Can t get appointment

23 Curiosities Underground Economy or Black Market Late patients sometimes rewarded, but adds to increased number of arrived Outperformed market so demand outstripped supply

24 Other Markers University Sampling Third next appointment: 1 day (for urgent or routine visits)

25 Patient Satisfaction Satisfaction rate Comparison to other offices Percentages 63.9% Satisfied 11.3% Neutral 24.8% Dissatisfied 65.4% Easier 14.0% Neutral 20.6% More difficult

26 Patient Satisfaction Conclusions Overall, patients are satisfied with Open Access Patient experience with the telephone system to schedule appointment has the strongest association with satisfaction There are some subgroups of patients who are more satisfied with Open Access, including patients <55 years old The 60/20/20 option of scheduling may better allow for patient needs

27 Suggested Readings/Websites Articles: Berwick CM. Escape Fire: Lessons for the Fature of Health Care. New York, NY: The Commonwealth Fund; Kennedy JO, Hsu jt. Implementation 0f an open access sheduling system in a residency training program. Earn Med ;35:666-6?0. Maeseneer JM, CePrins L, Gosser C, Heyerick 3. Provider conrinuir In family medicine. Ann Earn Mel 20034: Murray M, Tanrau C. Same-day appointments: exploding the access paradigm. Earn Proct Memag. 2000;7:45-50.\ Murray M. Answers to your questions about same-day scheduling. Fern Pract Manag : Murray M, Berwick, CM. Advanced access: reducing wairing arid delays in prirna care. JAMA. 2003:289: Nutting PA, Goodwin MA, Flocke SA, Zy:anshi Sj, Franc KG. Continuity of primary care: to whom does it matter and when? Ann Earn Med. 2003:1: O Hare CD, Corlerr J The outcomes of oren-access scheduling. Earn. P,-acr. Manag. 2004;11: Schegr F The end of the trng inp Trn iesie ri crrs e r nih recic ie Med. 2005:37: StemhauerJR, Koreli K, From 3, Spann.J. lnrplemerirtng open access schojua,ne rn an acaclemic pracrice. Earn Erect Mariag. 2006:13: Katherine D. Rose; Joseph S. Ross; Leora I. Horwitz. Advanced Access Scheduling Outcomes: A Systematic Review Arch Intern Med 2011; 0: archinternmed v1-10 Open Access Scheduling Reply George P. Valko (June 2, 2011). Chapter: Valko GP: Open Access Scheduling. In Nash DB, Skoufalos, A, Hartman, M, Horwitz, H (eds) practicing medicine in the 21st century, American College of Physician Executives, , October, Website: Institute for Healthcare Improvement: Family Medicine Digital Resource Library. Valko GP: Open Access Curriculum Society of Teachers of Family Medicine: Future of Family Medicine Task Force s Competency Based Curriculum. Meetings: Institute for Healthcare improvement (IHI) Annual lnrernarional.surnmit on Redesigning r.he Clinical Office Practice. (An excellent meeting for all aspects of clinical office desicn with a chance to talk to those who have uone:r, See website above)