Same-day appointments whittle backlogs
Visits to provider of choice create service capacity
To offer every patient an appointment today even if it’s not urgent — that’s the standard at Kaiser Permanente in Roseville, CA.
"We’re beyond measurement; it’s a system imperative," says Mark Murray, MD, MPA, assistant chief of medicine and director of the Appointment & Advice Call Center.
Desperate need for change
Reaching that status was no easy feat, given 55-day waits for routine appointments in the early 1990s. A flat growth rate and poor image among Kaiser’s nonmembers, however, spelled slow death unless they worked down the backlog. Achieving the no-wait state took dogged work and other tactics, including the following:
1. replacing the old assumption of insatiable consumer demand for health care services with the emergent understanding that, as consumers, most of us simply want to see our own doctors when we have a health concern;
2. learning to predict ambulatory service demand and adjust supply through principles similar to those applied in other service industries — grocery stores, hotels, and restaurants;
3. evolving to a second-generation definition of "open access" in ambulatory care.
Second-generation access
Sometimes we just have to try something to learn it doesn’t work. It was that way with early attempts to shape or divert health care service demand. The following are two notable learning experiences from first-generation efforts:
- Advice nurses are not only expensive, but they defer utilization, according to Catherine Tantau, BSN, MPA, special project coordinator for the Valley Service Area of Kaiser Permanente, also in Roseville.
She notes, "We now know that 30% of patients who talk to an advice nurse show up later in the emergency room or for an urgent or routine appointment. That’s one way systems unwittingly clog up their access."
- Open-access systems defer utilization and diminish customer satisfaction consumers by cutting out same-day matches between patients and their own providers or only offering same-day appointments urgent care.
Chiseling down their daunting delays required the Kaiser group to implement two second- generation principles of efficiency and patient access in ambulatory care:
- Live by the motto, "Do all of today’s business today." That means seeing all of the patients and doing all of the paperwork. Like excess inventory in a factory, backlogged appointments cramp a clinic’s capacity to respond to the unexpected, Tantau explains.
- Offer patients the following choice: "Would you like to speak to the nurse, or would you like to make an appointment with your doctor or a nurse?"
Though some prefer a future booking, 75% to 80% accept a same-day appointment, Murray notes. Either way, they hear the comforting words, "Your doctor can see you today."
No excuse not to know
Grocery stores have figured out when their demands ebb and flow, "and there’s no excuse for health care not to know what drives ours," Tantau argues. It doesn’t take genius, just observation of the drivers in your marketplace, she continues.
If you’re in a pediatric market, May and June will bring summer camp physicals, and August, school physicals. When do allergies strike in your climate? It was monitoring such factors that reduced Roseville’s bad flu outbreak of 1997-98 to a non-event, Murray notes.
Kaiser Roseville manages demand as follows. When a doctor sees a patient with a cold, he or she explains home remedies then adds, "This is what the nurse would tell you also, in case you have to call again. I’m going to give you this handout so you can review what I’ve told you to do. And, since you’re here today, would you like to get your annual physical done?"
Those techniques create capacity in the system by opening up an appointment later, Murray explains, as long as the provider offers them as options. Sometimes a person suffering from a cold feels too rotten to stay for a physical exam.
Once you learn how to forecast demand, it’s time to adjust your service supply. At Mercy Healthcare Arizona in Phoenix, a mixed capitation and fee-for-service practice, the staff are encouraged to vacation in the summer months when the tourist population is low.
Mercy’s director of Practice Administration, Sherry Delio, MPA, explains that during the summer, they post notices for patients, who are mostly locals, that there’s no wait for routine physicals.
The road to same-day status
When Tantau and Murray introduced the idea of working down the 55-day wait, many employees said it was crazy, especially since the facility was locked into a tight budget. Hard, extended hours and a better supply ordering system brought the results some thought impossible. (For details of the supply ordering project, see QI/TQM, December 1998, p. 160.)
At Mercy, they created capacity by taking the following steps:
- Providers finished most 40-minute appointments early, so check-in to check-out cycles were accelerated to 30 minutes.
- The greater the lead time between the booking and actual appointment, the greater the no-show rates. So they book extra appointments when predicted no-shows exceed 5%.
- Two-hour staff meetings have been reduced to shorter time frames.
- For the first appointment slot of the morning, they schedule one short visit and one routine physical. While the provider completes the short visit, support staff prepare the other patient for the physical exam.
The element of delight
Having achieved same-day status, providers at both Kaiser and Mercy love it and wouldn’t dream of going back. "They’re able to delight their patients with timely appointments. And they have the satisfaction of seeing and managing their own patients over time," Tantau says. It’s an accountability shift, she notes.
In the old days, doctors were responsible for seeing as many patients as possible; wait times didn’t matter. Now, the accountability is to a defined patient group. "Our medical teams have self-governance," Tantau explains. "When one provider is gone, it’s clear who will take care of the demand."
While that works at Kaiser because the 15 teams of eight-providers each know when they have full panels of patients, it’s less clear cut at Mercy.
"In a fee-for-service world, it’s difficult to monitor the size of your practice because the doctors don’t know if the same patients will come back next year or if they will switch to another doctor," says Delio. She explains that monitoring practice size in fee-for-service models is up for study by the Boston-based Institute for Healthcare Improvement (IHI).
Comparative improvements rates of backlog reduction at Kaiser Roseville and Mercy once again confirm the wisdom of shared learning, one of IHI’s hallmarks.
In fact, Delio, Murray, and Tantau are on the advisory group and faculty of IHI’s Collaborative on Improving Efficiency and Access to Care in Physician Offices and Clinics. While Murray admits that the Kaiser team "made every mistake you could make" during the 2½-year initiative to erase their backlog. By avoiding such mistakes, Mercy did it in four months.
(See graph, "3rd Next Available Routine Seen within 10 Days," p. 22.)
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