By Philip J. Tuso, MD, FACP;
Ken Murtishaw, RN, MA, DHE; Wadie Tadros, MD
The Easy Access Program is a model plan to improve personalized
care and patient access to primary care practitioners. In this
model, Health Plan members who call for an appointment can see
a clinician from their primary care module team within 48 hours.
This article describes the background, rationale, design,
and positive results of implementing this model access plan.
Introduction
After months of planning and after educating our physicians
and staff, the Easy Access Program started on June 1, 1998, at
the Southern California Permanente Medical Group (SCPMG) Antelope
Valley Medical Offices. The Easy Access Program was created to
solve problems of patient and staff dissatisfaction with our appointment
system. Identified problems included long waiting time for appointments
and inability of members to schedule an imminent, timely appointment
with their primary care physician. In addition, clinical teams
"added-on" patients to fully booked schedules each day;
consequently, physicians' and other staff's stress levels were
high. These issues are not limited to our clinic but have been
reported elsewhere.1-5
The system's inefficiency caused members to schedule more than
one appointment for the same medical problem to help ensure being
seen when the need arose. As a result, our no-show rate (ie, rate
of patients who neither kept nor cancelled scheduled appointments)
was 22%. Because appointments with members' regular practitioners
were nearly impossible to obtain on a same-day or nearly same-day
basis, the volume of patients using the Urgent Care Department
began to rise and ultimately exceeded 50% of all adult primary
care visits. Our system required considerable "rework,"
ie, follow-up visits to other, nonurgent care departments for
medical problems not addressed earlier in the Urgent Care Department.
Working Within the Supply-and-Demand Model
of Health Care
Before changing our appointment system, we had to determine if
the number of appointments provided by our system (ie, the supply)
was large enough to meet our members' needs (ie, the demand).
"Demand" in this context is defined as the number of
patients seeking services--patients who call the clinic for advice
or unsuccessfully seek service plus patients who obtain an Urgent
Care or a routine appointment. The supply-and-demand model for
health care hypothesizes that our appointment capacity meets the
needs of our Health Plan members. Studies of our clinic population
show a mean of approximately 3.0 appointments per year per adult
member: 116,529 appointments made during a 12-month period divided
by 37,685 adult members.
Given that a full-time equivalent (FTE) clinician in our system
works five days per week, spends six weeks per year outside the
clinic for continuing education and vacation, and can be scheduled
for 22 appointments per day, each clinician can be scheduled for
5060 appointments per year (ie, 5 days/week X 22 appointments/day
X 46 weeks). By definition, this figure is our projected supply
of appointments.
According to these calculations, we need 23 full-time clinicians
to care for our member population (ie, 116,529 appointments divided
by 5060 appointments). Our supply of appointments must take into
account the total number of clinician hours spent in the clinic.
These clinicians include our full-time staff clinicians, extra
clinicians, per diem practitioners, and clinicians working in
the Urgent Care Department.
The supply-and-demand model should be used to guide a medical
center to operate more efficiently. When, for example, patient
panel size (ie, number of members assigned to a primary care practitioner)
increases to the point that the need for appointments exceeds
the number available, then demand exceeds supply, the system becomes
less productive, employee stress levels rise, and satisfaction
is decreased. At that point, members might leave the health care
organization, causing a decrease in revenue and consequent rise
in costs. In addition, a decrease in patient panel size and clinic
FTE ratios would decrease the need for clinicians, and costs would
begin to rise because salaries would exceed revenue. The ideal
ratio of panel size to clinic FTE matches the supply of appointments
to the demand for them.
Groundwork for Solving our Access Problem
Important work in the area of access within the Kaiser Permanente
system had already been reported by Murray and Tantau,3
who showed that an open-access system improves members' satisfaction
and decreases waiting times for return appointments. Data presented
by these authors3 and others4 were instrumental
in allowing us to develop the concepts that were successfully
implemented in our clinic.
After we determined that our appointment capacity was sufficient
to accommodate development of an Easy Access Program, we examined
ways to improve our office efficiency. "Brainstorming"
sessions with staff members identified two major areas of hidden
capacity at our clinic: 1) a high percentage of patients who neither
keep nor cancel a scheduled appointment, and 2) patients who are
seen in the Urgent Care or Emergency Departments and are later
seen by the primary care clinician for the same medical problem
within one week after the initial visit. The Ambulatory Satisfaction
Questionnaire (ASQ) survey was used to compare members' general
satisfaction with the Health Plan--and, in particular, their satisfaction
with our appointment system--before implementation of the Easy
Access Program.
A Gantt chart was developed to identify clinic stakeholders,
and teams were formed to address issues relating to implementation
of the program. In addition, we analyzed the function and length
of appointments and developed appointment types that would guide
our call center personnel to give members the type of appointments
they need.
Design and Implementation of the Easy Access
Program
As an initial step in designing the new system, we agreed that
all appointments would be 20 minutes long to avoid confusion between
the 15-, 30-, and 45-minute appointment types used in our old
system; 15-, 30-, and 45-minute appointments were eliminated.
The call center receptionist scheduling an appointment would thus
need only to look for one appointment type--the type which most
members request. Appointment types were reviewed with the primary
care provider teams, and 18 appointment types were replaced with
four: hold, new, return, and same-day. Adjustments were made to
accommodate Family Practice clinicians who provide pediatric services
and other procedures on a same-day basis.
When members call for an appointment in our new system of access
to care, the call center receptionist determines if the patient's
primary care clinician is available for a same-day appointment;
in this sense, the new system is resource-specific. If an appointment
is available, the receptionist gives the member the appointment;
if the clinician is not available for a same-day appointment,
the call center representative identifies another module team
member who is available; in this sense, the new system is module-specific.
If no module provider is available, the receptionist identifies
an available clinician within the department; in this sense, the
new system is department-specific. If no same-day appointments
are available, the member is given an appointment in the Urgent
Care Department.
Categories of future appointments were identified as "new
member entry," "preoperative screening," and "hospital
follow-up." Clinic staff who interact with members needing
these appointments were given the responsibility and authority
to schedule future appointments for these patients.
To accommodate this change, the Medical Records Department had
to change its chart-delivery system: instead of pulling charts
only for routine future appointments--and thus deliver charts
once or twice per day--personnel had to be available to pull charts
and deliver them to the module several times per day on an as-needed
basis.
Knowing that the long-term success of the program depended on
encouraging both accountability and the potential for rapid change
at the local level, we developed module teams consisting of nurses,
physicians, pharmacists, social workers, receptionists, and clinical
assistants and including a physician as team coleader and a nurse
as team coleader. Teams met daily, weekly, and monthly to discuss
quality and performance improvement issues. Original thought was
encouraged. Every month, all module teams met jointly to share
best practices. A physician master scheduler reviewed vacation
and other absences to assure that not more than two providers
from the module would be absent at one time. Module leaders were
responsible for scheduling a clinician to be present in each module
for after-hours clinic appointments.
The final step before implementing the Easy Access Program was
to reduce the backlog of patients on the clinic or medical center's
appointment waiting list. One way to reduce the backlog would
be for the clinic to increase the number of providers available
to meet the future demand for appointments; however, this method
is costly and generates a new list of patients waiting to be seen.
In our clinic, therefore, we telephoned most of the patients on
the waiting list and discovered that 25%50% of these patients
did not need a return appointment. Instead of being sent a card
with appointment date, the remaining patients were sent a letter
reminding them to call for an appointment. After initiating this
process, our backlog was eventually reduced to a number which
was easily absorbed by our new access program.
Results
The numbers of no-show appointments for the five months before
and seven months after implementation of the Easy Access Program
are shown (Figure 1). The no-show rate
dramatically decreased after we started the new program on June
1, 1998. The overall no-show rate decreased a mean of 857 appointments
per month (for the five-month period before the program started)
to a mean of 312 appointments per month (for the seven-month period
after the program began). This decrease corresponded to a reduction
in no-show appointments from about 214 per week to 78 per week.
The most dramatic change among the four types of appointments--hold,
new, return, and same-day--was seen for return appointments (Figure
2).
Because the new system allowed for same-day appointments, the
number of appointments added to clinicians' schedules was substantially
decreased from a high of 639 (in April, 1998) to a low of 42 (in
August, 1998) (Figure 3). In addition,
because clinicians had increased their capacity to see Health
Plan members in the primary care clinic, the percentage of Health
Plan members seen in the Adult Urgent Care Department decreased
from 48% to 29% after implementation of the Easy Access Program
(Figure 4).
The Internal Medicine Department waiting list for routine appointments--an
indicator of unmet demand--was reduced from a mean of 852 per
month to a mean of 20 per month (Figure
5), a result which took about three months. After one month
of experience working within the Easy Access program, we randomly
surveyed several clinicians and receptionists to determine their
opinions about the program. On a scale of 110 (a score of 10 was
most positive), both groups gave the program a score of 8. Results
of the patient satisfaction questionnaire asking for patients'
appraisal of physician and staff services showed dramatically
improved patient satisfaction after implementation of the Easy
Access Program--both for individual indicators of satisfaction
and for overall satisfaction (Table 1).
Conclusion
The reasons for us to consider changing our present appointment
system were related to specific clinic issues: Our member satisfaction
scores were the lowest in our service area; no-shows (ie, appointments
that are neither kept nor cancelled) contributed approximately
20% of all primary care visits scheduled per day; and the number
of visits to the Adult Urgent Care Department per day was exceeding
the number of visits to nonurgent care clinicians per day. Our
system encouraged patients to schedule follow-up visits for medical
problems addressed earlier at the Urgent Care Department, yet
members did not perceive visits to the Urgent Care Department
as a satisfactory replacement for seeing their primary care practitioner.
The Easy Access Program implemented at the Antelope Valley Medical
Offices has made our clinic more efficient, has changed the way
we work with our internal and external customers, and has increased
their level of satisfaction with the Health Plan. We have decreased
the number of wasted appointments as well as the aggravation felt
by clinicians as patients are added to schedules that are already
fully booked. In addition, physicians and support staff now communicate
daily, weekly, and monthly to monitor and improve patients' access
to appointments. The overall benefit of the Easy Access Program
is development of a system of health care delivery that matches
appointment supply with appointment demand.
We hope that further evaluating this system will help us to develop
a program that fully meets both the acute and long-term needs
of our members while reducing unpredictable deficiencies in appointment
scheduling. Further work is needed to integrate the Easy Access
Program with population care management programs and to accommodate
members who want to schedule an appointment with their clinician
in excess of 48 hours. The data presented in this paper suggest
that the Easy Access Program may make our system of health care
more efficient while meeting access needs of our members.
References
1. Forsyth RA. HMO productivity: back to basics. Manag Care
Interface 1998 Jan;11(1):80-4, 87.
2. Pal B, Taberner DA, Readman LP, Jones P. Why do outpatients fail
to keep their clinic appointments? Results from a survey and recommended
remedial actions. Int J Clin Pract 1998;52:436-7.
3.Murray M, Tantau C. Must patients wait? Jt Comm J Qual Improv
1998;24:423-5.
4. Kersey P, Swanson JA, Dankbar E. Making primary care accessible.
Ambul Outreach 1998 Summer:22.
5. The three components of a patient-friendly scheduling system.
Qual Lett Healthc Lead 1997 Jan;9(1):14-5.
