Abstract
PROBLEM BEING ADDRESSED
Patients in a family practice had to wait 6 weeks for an appointment.
OBJECTIVE OF PROGRAM
To improve patient care by facilitating access to timely appointments.
PROGRAM DESCRIPTION
An FP from Halifax, NS, implemented advanced access in her practice. Advanced access is a same-day booking system, which has been shown to reduce or eliminate patient backlogs without the addition of resources. Theoretically, it can be put into effect in any practice with a stable backlog (which indicates that supply and demand are well matched). The first step to implement the advanced access system was to clear the existing appointment backlog. During a 6-week “boot camp” period, all prebooked patients and patients who called requesting same-day appointments were seen (between 50 and 60 patients per day). Same-day appointment rules apply to almost all patients. Staff begin accepting calls at 8:00 AM, and patients request the most convenient time available.
CONCLUSION
Baseline and postimplementation data are not available, as this was not a formal research study. Nevertheless, this FP from Halifax who implemented advanced access experienced the following in her practice: elimination of patient backlog, fewer no-shows, patients’ happiness with the system, increase in physician and staff morale, and stability in physician income. Formal feasibility studies and research evaluating patient outcomes, cost effectiveness, and physician and patient satisfaction in a variety of practice settings would help Canadian FPs decide if same-day booking could be successfully implemented in their practices.
RÉSUMÉ
PROBLÈME À L’ÉTUDE
Dans une clinique de médecine familiale, les patients devaient attendre 6 semaines pour un rendez-vous.
OBJECTIF DU PROGRAMME
Améliorer les soins en facilitant l’accès à une consultation entemps opportun.
DESCRIPTION DU PROGRAMME
Un médecin de famille (MF) d’Halifax, N-E, a instauré un meilleur système d’accès dans sa pratique. Il consiste à prendre les rendez-vous le jour même, un système qui a fait ses preuves pour diminuer ou éliminer la liste d’attente sans ressources additionnelles. Théoriquement, il peut être instauré dans n’importe quelle clinique possédant une liste d’attente stable (indiquant un équilibre entre l’offre et la demande). La première étape dans la mise en place du système consiste à éliminer les rendez-vous en attente. Au cours d’une intense période de rodage de 6 semaines, tousles patients ayant déjà un rendez-vous et ceux qui avaient appelé le jour même étaient vus (entre 50 et 60 patients par jour). La règle du rendez-vous le jourmême s’applique à presque tous les patients. Le personnel accepte les appels à partir de 8 heures et les patients choisissent le meilleur moment disponible.
CONCLUSION
Il n’existe pas de données pré et post instauration puisqu’il ne s’agit pas d’une étude expérimentale formelle. Néanmoins, le médecin qui a instauré ce système dans sa clinique a constaté ce qui suit: élimination de la liste des rendez-vous en attente, moins de rendez-vous manqués, satisfaction des patients, amélioration du moral du médecin et du personnel, et stabilité du revenu du médecin. Des études de faisabilité et des recherches pour évaluer les issues des patients, le rapport coût/efficacité, et la satisfaction du médecin et du patient dans divers contextes de pratique permettraient d’aider les MF canadiens à décider si ce système peut être instauré avec succès dans leur pratique.
Many primary care practices in the United States, Australia, and the United Kingdom have implemented a same-day scheduling system, also known as advanced access, open access, and easy access.1 Dr Mark Murray,2 the pioneer of this system, and others report on its successful implementation in huge American health maintenance organizations, in group practices with multiple full-time3,4 and part-time physicians, in academic practices,5 in pediatric clinics, in fee-for-service and salaried settings, in residency family medicine centres,6 and in solo practitioner offices.7
According to a report by the College of Family Physicians of Canada,8 Canada ranks poorly in terms of offering patients same-day access to their doctors. In 2004, only 27% of Canadians could obtain a same-day appointment, compared with 33% in the United States, 41% in the United Kingdom, 54% in Australia, and 60% in New Zealand. Canada also ranked last in this same group of countries in terms of percentage of patients waiting 6 or more days to see a physician (25% of Canadians vs 7% of Australians). While the broader societal problem of access will only be solved through a comprehensive national strategy to ensure an adequate and sustainable supply of family physicians, advanced access is a practice-management system that allows individual doctors to tackle wait times in their own practices.
Objective of the program
My family practice, based in Halifax, NS, had several practice-management problems familiar to many Canadian FPs: 6-week wait times for appointments, delays in the waiting room, high telephone and reception desk traffic, long workdays, and disgruntled patients and staff. I feared these factors were undermining 2 essential goals of primary care—access and continuity of care—both of which are important factors in patient satisfaction and outcomes. I decided to switch from the traditional booking system, which I’d been using for the past 21 years, to same-day booking—which would reduce waiting times for patients to obtain appointments.
At the time I implemented same-day booking, I did not envisage a formal research project or evaluation, so the description that follows is anecdotal and is not intended to be viewed as a rigorous evaluation of the system. My goal is to share my experience with other physicians and hopefully encourage formal research in Canada to help physicians make informed decisions about whether advanced access might be a feasible option in their practice settings.
Program description
Advanced access borrows principles from industrial engineering and queuing theory to reduce or even eliminate delays without adding resources. At the heart of this model is a rejection of the concept of 2 streams of patients, namely routine and urgent. The mantra of the system is to “do today’s work today.”1 By seeing all patients today, the model has been shown to eliminate backlogs and the need to triage patients (thereby freeing staff for other tasks); to reduce interruptions, telephone callbacks, and appointment confirmation; and to dramatically decrease the number of no-shows.1,7
As advanced access is a process, as opposed to a specific solution, it can be applied to a variety of settings, but requires thought, customization to a given setting, and experimentation.9 It is also more likely to succeed if physicians are engaged and all relevant staff are involved early in the process.9 In order to be successfully applied in a health care setting, the system requires a balance between patient demand and physician capacity. Practices must, therefore, have a thorough understanding of the size of their patient population, the demand for appointments, and physician capacity (ie, number of available appointments).
Once the feasibility of implementing the system is established, the next step is a one-time, up-front elimination of any backlog. Strategies for backlog elimination include adding capacity, enhancing telephone and e-mail interactions, outside referrals, or use of locum tenens.1 In order to simplify scheduling, the number of different appointment types and lengths are reduced.1 Contingency plans might be required for high-demand times, such as flu shot season or extended physician absences. Prescheduled appointments are not denied to patients who need them; however, if possible, their appointments should be scheduled to coincide with periods when demand is lower in a given day or week. Ongoing monitoring of demand and future open capacity is also recommended in order to sustain and fine-tune the system. Table 17 explains the steps to implement advanced access. Detailed information on how to measure and monitor these variables and how to implement same-day booking in a variety of practice settings is available in an excellent manual entitled Advanced Access in Primary Care,10 as well as in the literature.1,2,9,11,12
Table 1.
Steps to implement advanced access
| 1. Determine and balance supply and demand | Using a simple tally sheet, prospectively measure daily demand for appointments by patients (external demand) and physician recall (internal demand).
Supply is easy to calculate, as it is simply a measure of the number of appointments the physician offers in a week. This allows return visits to be reallocated to low-demand days and physician shifts to be rescheduled for high-demand days. |
| 2. Eliminate the existing backlog | This is done once and up front, and requires any or all of the following:
|
| 3. Simplify appointment types | Standardize appointment lengths (eg, 15 minutes) and use multiples of that standard appointment, if necessary.
Do not “reserve” emergency appointments. There should be enough capacity to meet each day’s patient demand. |
| 4. Monitor and plan for variations | Monitor and plan for variations to supply and demand due to busy times, planned absences, epidemics, etc. |
Adapted from Knight et al.7
Practice structure
Before implementation of advanced access, my practice consisted of 2 physicians—myself and an associate—with approximately 2000 patients each, 2 examination rooms, and the potential for each physician to see 25 to 30 patients per day. Although we had 2 rooms, my associate and I worked different shifts; so during my shift, both rooms were available to me. Staff resources included 1.5 staff members and 2 telephone lines. Patients had to wait approximately 6 weeks for an appointment. Within each day, staff tried to “save” appointment slots for sick people, but this generally resulted in my working longer hours in order to see these patients. In a typical fully booked day, approximately 5 patients required urgent or same-day care and were slotted into “saved appointments,” if any were available, or were double-booked.
In my attempts to accommodate patients requiring same-day care, I inevitably fell behind schedule. In addition, patients often presented with seemingly simple issues that were, in fact, more complex, or with a long list of complaints they wished to address in a single appointment. The result was often a waiting room filled to capacity and patients waiting for more than an hour beyond their allotted appointment time. I, along with staff and patients, was unhappy and stressed. I decided to convert my booking system to advanced access, while my associate continued with a traditional booking system.
Implementation
First we needed to assess the feasibility of switching to same-day bookings in my practice. For 1 week, staff logged the number of calls from patients requesting appointments and the number of follow-up appointments (which I had requested) per day. I had the capacity to see about 25 to 30 patients per day, which approximately matched the mean number of patients requesting appointments. As our supply and demand were well matched, we determined that advanced access would be feasible in our setting.
The next step was to clear the appointment backlog. This required a 6-week “boot camp,” during which time I saw all prebooked patients and patients who requested a same-day appointment. I saw 50 to 60 patients per day, and most days I worked from 8:30 AM to 6:30 PM.
The new system also required new rules. Patients who called during the “boot camp” period were advised about the same-day system that was being implemented. Staff begin accepting calls at 8:00 AM each day, and patients can request the most convenient time available. Available visit slots are 10, 20, or 30 minutes long; time slots are booked depending on patient requirements. Appointments for the day are usually filled by 10:30 AM.
Postimplementation
By using the same-day booking system, almost all patients are seen. On average, I see 5 or 6 patients per hour. This includes prenatal visits, full physical examinations, nonurgent psychiatric visits, and chronic disease follow-up visits. For some patients, I use strategies such as prescribing medication in limited quantities and dated bloodwork requisitions to trigger follow-up visits. For example, patients with diabetes leave my office with a 3-month supply of oral antihyperglycemic agents, a dated bloodwork requisition to ensure they have quarterly hemoglobin A1c and fasting blood glucose tests, and instructions to call for an appointment when their medication is starting to run low.
An exception to the same-day policy is that bookings for the first half hour of each morning are filled by patients who call on the previous day. Exceptions to same-day bookings are also made for people with cognitive impairments, those who must prebook transportation, and those who cannot access a telephone early in the day. I will also prebook psychiatric patients in crisis as part of a contract with the patient to check in with me regularly. Failure of these patients to present at these prebooked appointments is a trigger for me to follow up with the patient or family. My staff and I try to limit prebooking to 4 or 5 appointments daily.
The same scheduling rules apply during my absences, with same-day booking commencing once I return. This allows me to cancel a clinic day, take a vacation, stay home ill, attend a conference, or look after family members.
Discussion
In a search of MEDLINE and various Internet-based resources on the application of advanced access in a Canadian health care setting, I was able to locate newspaper articles and newsletter articles on advanced access used in practices in Winnipeg, Man,13 and Saskatoon, Sask.14 I did not locate any published assessment of advanced access in a Canadian setting in the peer-reviewed literature. Despite my experience not being a formal assessment of advanced access, these are my anecdotal observations of the system:
Backlog
One of my primary objectives was to eliminate patient waiting times, and advanced access has enabled me to accomplish this. My backlog has been eliminated and patients who request an appointment are now seen within 1 day. Our calculations of a balanced supply and demand have been supported by our finding of only a few empty appointment slots each month. These empty slots are often related to inclement weather.
No-shows
My staff members report fewer no-shows. This finding is consistent with many advanced access reports that show a decrease in no-show rates.7,15 For example, in the health maintenance organization Kaiser Permanente, no-shows decreased from almost 20% to virtually zero15; however, some authors report no significant changes in no-show rates.4,6
Working conditions
Consistent with other reports,3,7 my staff’s working conditions have improved; they spend less time triaging patients, searching for and changing appointments, and explaining appointment unavailability to patients. There is also less traffic at the reception desk and a less congested waiting room. Ahluwalia and Offredy16 described advanced access as a process of “converting their [receptionists’] perceived role from gatekeeper to access facilitator.” Steinbauer et al5 reported a 36% reduction in rescheduling of appointments.
Dixon et al17 noted staff frustration with verbal abuse from patients who cannot get through on the telephone. Some of my patients have also expressed frustration at long hold times. Our telephone is very busy first thing in the morning (although this is not a new problem). Apart from this early morning busy period, however, there are fewer telephone calls during the day, as patients are not calling to check or change appointments.
Physician morale
My morale has certainly increased. I am happier and I have greater control over my workday. I also believe I provide timely patient care. There was no cost to implement the same-day booking system, and my income has remained stable.
Patient care
My ability to now see my patients as soon as they need to be seen has likely resulted in better continuity of care. By finding their illnesses earlier, I am able to intervene earlier. In addition, many of my patients are coming in with shorter complaint lists. They tend to schedule a visit for a specific issue rather than accumulating complaints as they wait for an appointment. Patients who could not see me in a timely fashion before tended to resort to the emergency room or to a walk-in clinic.
Patient satisfaction
Several months after implementation of the new system, my staff conducted an informal survey of patients. Over a 1-week period, staff handed out questionnaires to a random sample of 100 patients. The survey was anonymous and patients deposited the forms in a sealed box in the waiting room. At the end of the week, the questionnaires were compiled. Consistent with the findings of more formal analyses of patient satisfaction,3–5,12 this informal sampling of my patients revealed that 93% were highly satisfied with the new system. It has been suggested that the system increases patient satisfaction because it provides patients with an assurance that their doctors will be available when they need them, which builds trust and reinforces the patient-physician relationship.18 One study (in which patient satisfaction was also rated as high) found that those patients who were concerned about not being able to prebook appointments listed chronic illness or busy personal schedules as the reason for their concern.5
Limitations
Theoretically, advanced access should work for any size practice with a stable backlog. The actual feasibility, however, would have to be determined by individual practices. The system might not work for practices that have a disproportionate number of cognitively impaired patients or patients who are dependent on others for transportation. Some detractors of the system cite concerns about the system for elderly17 and chronically ill patients, fearing that planned chronic care visits and close follow-up are essential and cannot be adequately accommodated using advanced access.19,20 Murray, however contends that advanced access actually creates more reliable opportunities for the intensive face-to-face encounters needed for optimal chronic care management.21 I, like most family physicians, have many elderly patients and patients with chronic disease. These patients have not expressed dissatisfaction with the system and I am confident that their care is not being jeopardized. Indeed, “improving access does not mean neglecting or ignoring needed follow-up for patients with chronic issues. Under advanced access, physicians can and should initiate needed visits just as easily as patients can.”21
Murray also believes that the main barriers to more widespread adoption of the system are psychological because the principles of advanced access run counter to widespread and deeply held beliefs about scheduling.1 Advanced access failures are usually related to lack of leadership, poor measurement (ie, a mismatch between supply and demand), lack of physician engagement in the process, and lack of engagement of the entire team.9 Ongoing vigilance is, therefore, needed to ensure that the system is operating well. I am particularly cognizant of the risk of “prebooking creep,” and have to watch this closely. I anticipate the need to make some refinements to the early morning telephone rush, which has been identified as a problem by some of my patients.
Conclusion
This article presents my experience implementing same-day booking in my family practice. Advanced access offers a rational change in the management of supply and demand, with no increased burden for physicians.1 Physicians, staff, and patients have expressed high levels of satisfaction with the system. Telephone calls, waiting room traffic, and no-shows have decreased, while my income has remained stable.
Formal feasibility studies and research evaluating patient outcomes, cost effectiveness, and physician and patient satisfaction in a variety of Canadian practice settings would help family physicians decide if advanced access could be successfully implemented in their practices and within the Canadian health care context.
Acknowledgment
I gratefully acknowledge the contributions of the following people: Dr Brendan Carr, Vice President, Medicine, for Capital District Health Authority; Dr Samuel G. Campbell, Associate Professor in the Department of Emergency Medicine at Dalhousie University; Mike MacDonald, Administrative Coordinator in Primary Care, Quality and Decision Support at Capital District Health Authority; Michelle Draper and Marilyn Healey, my clinic receptionists, who were invaluable in implementing the advanced access system; and Cynthia N. Lank, who provided editorial assistance. Funding for the development of this manuscript was provided by Capital Health
EDITOR’S KEY POINTS
Traditional booking systems might result in low satisfaction for patients, physicians, and staff.
Same-day scheduling systems can reduce appointment backlogs, the need to triage patients, and staff telephone time.
Careful planning is required to implement the new system, including a “run-in” period to reduce the appointment backlog.
POINTS DE REPÈRE DU RÉDACTEUR
Le système traditionnel de rendez-vous peut engendrer un faible niveau de satisfaction chez les patients, les médecins et le personnel.
Inscrire les rendez-vous le jour même peut diminuer le temps d’attente, le besoin de triage et le temps que le personnel passe au téléphone.
La mise en place du nouveau système nécessite une plani_cation minutieuse, incluant une période de «rodage» pour réduire la liste d’attente.
Footnotes
Competing interests
None declared
This article has been peer reviewed.
References
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