Advanced Access: How To Make it Work, Part I -Appt Demand and Supply Forecasting -Backlog Reduction Catherine Tantau, BSN, MPA President, Tantau & Associates Tantau & Associates P.O. Box 179 Chicago Park, California 530-273-6550 ct@tantauassociates.com 1 2 1
Objectives Part I Identify the key High Leverage Changes to reduce waits and delays for care. Learn now to analyze your practice s appt demand, supply and activity and strategies for correcting imbalances Understand how to draft an Appointment Backlog Reduction Plan. Define the importance of using both Hard and Smart strategies for successful and sustainable Backlog Reduction. 3 4 2
High Leverage Changes for Access Improvement 1. Match Appt Demand and Supply Daily, Weekly 2. Reduce Backlog 3. Decrease Appointment Types, Times, Restrictions 4. Develop Contingency Plans 5. Reduce Demand for Unnecessary Visits 6. Optimize the Care Team 5 Sequencing for Advanced Access Many options; one example of a tested path Set Access Aims Primary Care; Empanel pts w PCP, Promote Continuity Specialty Care: Establish method for input equity Measure delay for routine appt for each provider Measure appt Demand and Supply and Activity Not necessarily linear, consider parallel processing Match Demand and Supply, daily Work down the Backlog Simplify appt types and time Develop Contingency Plans Reduce demand for unnecessary visits Optimize the Care Team At every step Track and display data Celebrate successes and failures! Tantau & Associates 6 3
What is Advanced Access? NO delays for an appointment. CONTINUITY for patients and providers. Doing today s work today and this week So how many appts do we need today? 7 A. What Drives Appt Demand? Illness Burden of Population Panel Size or Case Load Delays and poor Continuity drive up 15% Practice style Wasson, Dartmouth Mood, Attitude, Customs UK, US, Canada, Sweden 3 PC visits /year Germany 6 visits/year France 12 visits/year 8 4
Appt Demand, Supply, Activity 3-D look at the practice by provider and by division Critical measures to forecast appt Demand patterns by division and by provider Appt Demand patterns guide Appt Supply patterns Appt Activity: at the end of the day, how many pts were seen? 9 Measuring Appt Demand Look at historical data? Worse case scenario Reassurance real time data Moment of Truth: Appt booking transactions 10 5
Appt Demand Formula True Demand Formula: External Appointment requests, called in and appted regardless of day appted. To (today or future) + Walk-ins for appts. + Other portals of entry?(email, fax, "add-ons etc.) + Deflections that arrive somewhere in system (UCC etc) Internal + Returns booked today for the future Total Demand 11 What are we counting???? Appts generated and booked today, for today or the future. Today s appt booking transactions for each provider. 12 6
What are we not counting??? What is already on today s schedule is irrelevant represents previous demand, not today s demand. All calls for appts. Pts often call multiple times for a single appt. All calls do not result in appt booked. 13 Who s done this? What did you find??? Surprises? Variation? 14 7
Appointment Demand Worksheet Date: Care Unit 3 Patients calling today, requesting appt, regardless of day appted to (External) Walk-Ins today appted (External) Deflections, eg UCC, if trackable (External) Return appts booked today as pts leave today s appt. (Internal) Total Demand Optional; Pts turned away, not booked. Do not add into Demand Provider A Provider B Provider C Provider D Total 15 Other external demand Measured demand Calls for visits Internal demand Monday 44 2 29 75 Tuesday 34 5 25 64 Wednesday 29 8 35 72 Thursday 30 3 18 51 Friday 37 1 31 69 # appt per day Appointment Capacity versus Demand Provider capacity Measured demand Provider capacity # appt per day Monday 70.125 Tuesday 61.5 Wednesday 87 Thursday 58.875 Friday 84 Visits per VISIT RATE hour Provider A 3 Provider B 3 Provider C 2.25 Provider D 3 Provider E 3 Provider F 3 100 90 80 70 60 50 40 30 20 10 0 Monday Tuesday Wednesday Thursday Friday HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AM Provider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5 Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5 Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875 16 8
Other Measured Calls for external Internal # appt per demand visits demand demand day Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Friday 0 Appointment Capacity versus Demand Provider capacity Measured demand Provider # appt capacity per day Monday 0 Tuesday 0 Wednesday 0 Thursday 0 Friday 0 Visits per VISIT RATE hour Provider A Provider B Provider C Provider D Provider E Provider F 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Monday Tuesday Wednesday Thursday Friday HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AM Fri PM Total Provider A 0 0 0 0 0 Provider B 0 0 0 0 0 Provider C 0 0 0 0 0 Provider D 0 0 0 0 0 Provider E 0 0 0 0 0 Provider F 0 0 0 0 0 Mon Total 0 Tue Total 0 Wed Total 0 Thu Total 0 Fri Total 0 17 B. Appointment Supply Appt slots on template normally available to each provider in dept. each day of the week. Track MLPs and physicians separately. 18 9
Appt Supply Macro Supply dept level Deployment of Supply bookable hours Measures Measure when schedule is released. Appts per session for each day of week per provider. Estimate % long and shorts based on prior schedules Hours per session? Productivity standard? Office FTE modification 19 Appointment Supply Worksheet Week of: Provider A Mon Tues Wed Thurs Fri Sat Total Supply Provider B Provider C Provider D Total 20 10
Other external demand Measured demand Calls for visits Internal demand Monday 44 2 29 75 Tuesday 34 5 25 64 Wednesday 29 8 35 72 Thursday 30 3 18 51 Friday 37 1 31 69 # appt per day Appointment Capacity versus Demand Provider capacity Measured demand Provider capacity # appt per day Monday 70.125 Tuesday 61.5 Wednesday 87 Thursday 58.875 Friday 84 Visits per VISIT RATE hour Provider A 3 Provider B 3 Provider C 2.25 Provider D 3 Provider E 3 Provider F 3 100 90 80 70 60 50 40 30 20 10 0 Monday Tuesday Wednesday Thursday Friday HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AM Provider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5 Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5 Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875 21 Tracking Demand and Supply source: YKHC, Bethel Alaska Supply & Demand 350 300 250 200 150 100 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Day of the Month Demand Supply S&D Average Weekly Averages W TH F Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average M T 197 186 174 159 161 159 156 216 211 168 146 176 261 240 235 208 184 Demand Demand Supply 171 179 195 179 201 176 164 192 174 150 118 173 Supply 193 190 162 195 175 250 Family Medicine Supply & Demand Daily Average by Month 300 Average Weekly Supply and Demand 250 200 200 150 150 100 100 50 0 50 M T W TH F 0 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average Demand Supply Demand Supply 22 11
C. Activity; the 3 rd Dimension Activity is the measure of patients who were actually seen today. At the end of the day, regardless of demand or supply, count the number of patients seen. Accounts for No Shows and Overbooks. 23 Demand, Supply, Activity Office Visits A three dimensional look at what s really going on in the practice. Number of Ap 1000 900 800 700 600 500 400 300 All Physicians (Totals) - Office Visits (HG only) Demand Activity Supply 200 100 0 Sept Oct Nov Dec Jan Feb Mar Apr May Source: Huron Gastro, Ann Arbor 24 12
Demand, Supply, Activity Procedures All Physicians (Totals) - Procedures (CDC & Imaging Ctr) 2500 2000 Number of Ap 1500 1000 Demand Activity Supply 500 0 Sept Oct Nov Dec Jan Feb Mar Apr May Source: Huron Gastro, Ann Arbor 25 Appointment Activity Worksheet Week of: Provider A Mon Tues Wed Thurs Fri Sat Total Activity Provider B Provider C Provider D Total 26 13
Do we really need more space? GI Clinic Capacity & Demand 40 36 patients providers rooms 32 28 24 20 16 12 8 4 0. Mon AM Mon PM Tues AM Tues PM Wed AM Wed PM Th AM Th PM Fri AM Fri PM. 27 Three Dimensions; Appt. Demand, Supply, Activity Obstetrics & Gynecology Average Supply & Demand December 12 - July 7 3 Appointments Per Hour 90 80 79 75 73 82 70 60 50 63 62 60 55 51 49 40 30 27 32 24 33 35 20 10 0 Monday Tuesday Wednesday Thursday Friday Supply Demand Patients Seen 28 14
Delay for appointments (Access) Obstetrics and Gynecology, Ministry Medical Group Womens Health 3rd Availability Long Appointments Days until 3rd Available 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 0 10/10/05 10/24/05 11/14/05 11/28/05 12/12/05 12/26/05 1/9/05 1/23/06 2/13/06 02/27/06 03/13/06 03/27/06 04/10/06 Scheduling Rules Eliminated/Standardized Appointment Types. 4/24/2006 5/8/2006 5/22/2006 6/12/06 6/26/06 7/10/06 29 Surgical Specialties OR Demand and Supply First, Measure Delay Next, long surgical slot 3 rd next, short surgical slot What do our demand numbers tell us about demand for surgeries per week? How does this compare with our deployment of supply? What can we do differently? 30 15
The Pile unbooked consults or surgeries 1800 1600 1400 1200 1000 800 600 400 200 0 Time Period New Consults Unbooked Consults Booked Consults 31 How to Track How long to track Tic Marks vs Electronic tracking 4-6 weeks and then forever Separating Internal from External 32 16
What s your situation? How do you know? D>S? D<S? D:S? ------------------------------------------------ Our schedules are jammed every day. Our Demand must outstrip our Supply (??????) We ve had the same Delay for months. We measure D and S, continuously and map the trends. 33 If Demand is Greater than Supply Four Options 1. Work harder? 2. Buy more Supply? 3. Delay the work? 4. Do the work differently!!! test. 34 17
4. Do the Work Differently. Shape Demand; the Monday vortex Eliminate duplicate visits; comb schedules Care Team development; leverage the work Huddles; include max pack opportunities Extend visit intervals Promote Continuity Simplify Appt types and times Nurse Appts, phone appts, Group appts, pt Portals, SMS Improve Access; reduce No Shows; re- capture Supply Go system-wide Other????? 35 Identify source of demand and ask, Why? Internal External Discontinuity Single issue visits to ramp up visit count? Bumping Delays and defensive booking Sub-optimized Care Team Growth 36 18
Decrease Internal Demand Demand variation pre and post procedure Return visit variation Graduation rates Internal Tantau & Associates 37 Disposition Percent # Visits Numerator1 (Black) : No. of appts patient given no disposition, or told, "if symptoms worsen or, >= 4 months. Numerator2 (Red ): No. of appts patient given disposition between 1-3 months or less. Denominator (Blue): Total number of face to face appts/month. Source: Contra Costa County, Medical Center, California 19
Embrace the data 39 Your Next Steps Identify 2 things you will do when you return to begin to measure appt demand, supply and activity. 40 20
2. Reduce Appt Backlog Are we there yet? Tantau & Associates 41 High Leverage Changes for Access Improvement 1. Match Demand and Supply Daily, Weekly 2. Reduce Backlog 3. Decrease Appointment Types, Times, Restrictions 4. Develop Contingency Plans 5. Reduce Demand for Unnecessary Visits 6. Optimize the Care Team 42 21
Good Backlog vs Bad Backlog 43 44 22
Backlog Planning Assemble your team Develop a written plan Set two dates Who plays??? 45 One way to handle Backlog 46 23
Backlog Reduction No substitute for hard work, however. 47 Sustainability comes from Smart Strategies 24
A. Backlog Plan: Smart Strategies Work backlog as a team Huddle Comb schedules Maximize visit efficiency Extend visit interval Manage follow up visits in a different way Leverage the work to others Support the team during backlog redux. Celebrate!!!!! 49 Set Two Dates Select a start date Select an end date 50 25
Do Increasingly More Of Today s Work Today Commit to it Don t add to the end of the queue Do more with today s visit Enlist the team 51 Work Backlog As A Team Daily Team Huddles Commit to continuity for appts Honor Continuity with PCP or specialist and Care Team. Can someone else on the team manage this problem? Beware of Negative Reward for early birds. 52 26
Look Ahead At The Schedules Check for duplicate visits and referrals comb the schedule. Will a telephone call suffice? Phone appts? UCSF General Family Medicine testing Can more be done at today s visit to eliminate a future visit? 53 Consider This A physician sees twenty patients a day for twenty days per month for ten months per year. If s/he is able to maximize one visit to reduce future demand, then this physician has saved 200 visits in a year. That is ten physician days. If a physician can appropriately extend the visit interval for fifty diabetic patients from three months to four months, then fifty visits are saved per year. That is 2.5 physician days. Better yet, use members of the Care Team! 54 27
Maximize Visit Efficiency Increase the value of the face-to-face clinician/patient time Eliminate physician distractions / interruptions Leverage the providers time remove clerical tasks Do more with some visits 55 Extend The Visit Intervals Specific patient Specific diagnosis or care pathway Eliminate or combine certain return visits 56 28
Disposition Percent # Visits Numerator1 (Black) : No. of appts patient given no disposition, or told, "if symptoms worsen or, >= 4 months. Numerator2 (Red ): No. of appts patient given disposition between 1-3 months or less. Denominator (Blue): Total number of face to face appts/month. Source: Contra Costa County, Medical Center, California Manage Follow-Ups In A New Way Can an RN or Health Coach follow-up with the patient? Can an NP or PA manage the care plan? Phone visit follow-up? Group visits? Tickler file reminder vs appt? 58 29
Sometimes a small change can make a big difference YKHC Physical Therapy Reduction in Delays for Appointments Third next appointment -PT 40 35 Stopped serial Booking of returns No. of Days 30 25 20 15 10 RH KH HJ 5 0 10/27/05 11/16/05 12/07/05 12/19/05 01/13/06 Date 01/18/06 01/27/06 02/06/06 (*)3/7/2006 03/17/06 03/29/06 59 B. Hard Strategies for Backlog Temporarily add daily capacity get ahead of your demand curve. Do increasingly more of today s work today add less to end of queue Identify team members roles and responsibilities for backlog reduction. 60 30
Temporarily Add Capacity Not too much Not too little Just right! 61 Commit to it! Do Increasingly More of Today s Work Today Don t add to the end of the queue Loosen the criteria for today Backlog slots are for your pts. Free up time for increased clinical time Suspend some meetings, use locums, extend hours. 62 31
Hard Backlog Strategies Add daily capacity Where? When? How? Some customization is good. Be clear! Make it easy to schedule your pts into your Backlog slots 63 Watch you Delay tumble. Innovative model Primary, specialty care x 15 years. System wide applications 1 0 0 8 0 6 0 4 0 2 0 0 5 / 3 1 /0 5 N U M B E R O F C A L E N D A R D A Y S U N T IL 3 R D A P P T 6 / 3 0 /0 5 7 / 3 1 /0 5 8 / 3 1 /0 5 9 / 3 0 /0 5 1 0 / 3 1 /0 5 1 1 / 3 0 /0 5 1 2 / 3 1 /0 5 1 / 3 1 /0 6 2 / 2 8 /0 6 P E D I O B /G Y N I M E D 64 32
Univ of South Carolina Family Medicine PCP Access Provider schedule Huddles 40.0balancing begin 3rd Next Available in Days: 31 to 12 days 37.9 Excel Care 35.0 35.1 Begins 35.7 33.6 30.6 Change in 28.9 templates 30.0 carve out 30.5 27.8 26.3 28.1 25.6 26.4 28.5 27.6 26.3 24.6 27.3 25.0 25.3 24.1 24.3 21.8 24.2 24.3 22.7 21.4 21.5 23.1 23.9 21.6 20.8 20.0 19.0 19.5 20.2 Formation of 19.3 19.4 17.6 17.4 16.1 clinical teams 16.5 16.7 17.0 15.7 15.0 14.5 15.0 13.9 10.0 5.0 12.7 10.6 12.2 12.7 11.7 11.2 9.3 10.3 7.1 7.2 14.5 9.9 9.8 10.2 8.6 7.6 7.4 17.7 14.7 10.1 4.4 21.9 17.4 9.6 6.1 18.6 16.5 13.8 13.1 12.1 11.0 10.9 11.1 0.0 Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May Jun. Jul. Sep Oct. 65 University of South Carolina Family Medicine 3rd Next Available in Days: 32 to 6 days 40 37.9 35 30 25 20 15 10 5 35.7 28.9 28.5 35.1 33.6 30.6 30.5 26.3 25.6 27.6 26.3 24.6 25.3 21.8 24.2 21.5 23.1 23.9 19.3 26.4 20.8 16.5 14.5 12.7 28.1 24.3 19.4 27.8 27.3 24.1 22.7 11.9 10.5 12.9 8.8 10.0 8.8 10.0 9.0 9.9 8.6 7.7 7.8 8.4 7.3 7.9 6.2 6.0 5.1 4.4 4.0 5.0 0 Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. 66 33
Swedish Health Care System JonKoping Dept of Internal Medicine Neurology Days r 450 400 350 300 250 200 150 100 50 0 Nurse-Managed Clinics in charge of schedules, all follow-up visits, searched for every opportunity to remove work from specialist Standardized protocols and pathways beginning with ER (most of their cases came from ER) 67 Thoughts To Consider Promote team communication daily huddles, standing agenda item at meetings. Collect data, analyze it, talk about it, share it, weekly. Gain commitment from the team Support the team Motivate the staff; they re ready Celebrate 68 34
Cautions Backlog reduction is hard work Prepare for effects on other services Be careful about rewarding the early birds with perverse incentives Beware the temptation to slide backwards when things get better, or worse! 69 BACKLOG REDUCTION Describe Actions Point Person Timeline Develop a Plan Set Start Date Set End Date Identify special needs Backlog Budget? Add Capacity daily Smart Strategies Look ahead in schedule Maximize visit efficiency Establish panels Promote continuity Incent/Support the team Use technology Communication plan Track and display metrics Celebrate milestones 70 35
71 Questions.. 72 36
Your Next Steps. Identify 2 things you ll do to prepare for Backlog Reduction. 73 BACKLOG REDUCTION Describe Actions Point Person Timeline Develop a Plan Set Start Date Set End Date Identify special needs Backlog Budget? Add Capacity daily Smart Strategies Look ahead in schedule Maximize visit efficiency Establish panels Promote continuity Incent/Support the team Use technology Communication plan Track and display metrics Celebrate milestones 74 37
References Tantau, C, Accessing Patient Centered Care Using the Advanced Access Model, Journal of Ambulatory Care Management, Vol.32, no. 1, pp.32-43, 2009 Improving Medical Office Flows and Efficiency, Catherine Tantau and Mark Murray, presentation 1998 Managing the Unexpected, Karl E. Weick and Kathleen M. Sutcliffe, University of Michigan Business School, 2001 Duffy TE. Urology advanced clinic access concepts. Presented at the 4th Annual International Summit on Redesigning the Clinical Office Practice, St. Louis MO, April 14 2003 Kilo, C.M., Triffletti, P., Tantau, C., & Murray, M. (2000). Improving access to clinical offices. The Journal of Medical Practice Management, 16(3):126:132. Kofoed L, Ramirez ME. Achieving same day access in a Veterans Health Administration mental health clinic. In press, Federal Practitioner. 2004 Murray, Mark, MD, MPA and Catherine Tantau, BSN, MPA. Same-Day Appointments Create Capacity, Increase Access. Executive Solutions for Healthcare Management, February 1999. Murray, Mark and Catherine Tantau. Sept 2000. Same-day appointments: Exploding the access paradigm. Family Practice Management, 7(8):45-50. Retrieved January 15, 2004: huttp://www.aafp.org/fpm/20000900/45same.html. Schall, Marie, Terry Duffy, Anil Krishnamurthy, Odette Levesque, Prashant Mehta, Mark Murray, Renee Parlier, Robert Petzel and John Sanderson. Improving Patient Access to the Veterans Health Administration s Primary Care and Specialty Clinics. Joint Commission Journal on Quality and Safety, August 2004, Vol. 30, No. 8 Raddish M, Horn S, Sharkey P. Continuity of Care: Is it Cost Effective? American Journal of Managed Care. 1999:5:727-734. Jon O. Neher, MD; Gary Kelsberg, MD; Drew Oliveira, MD, Improving Continuity by Increasing Clinic Frequency in a Residency Setting, Family Medicine Journal, Vol.33, no. 10 p 751, November - December 2001 Francis G. Belardi, MD, Sam Weir, MD, Francis W. Craig PhD, A Controlled Trial of an Advanced Access Appointment System in a Residency Family Medicine Center, Family Medicine Journal, 2004 38