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Open Access Scheduling
Prevents Delays in Care

By Lisette Hilton
Lisette Hilton is a writer for Physicians Practice

Janis Dillard, chief operating officer at Family Health Center of Battle Creek, had spent a year learning about open access, a patient scheduling model that emphasizes seeing patients on the days they call for appointments. But, she had yet to begin implementing it at the practice. "It's a very scary thing, and it seems overwhelming," she said from her practice located in Battle Creek, Mich.

Then, one of the physicians approached her at the end of a long, hard day and told her, "I can't do this anymore. We're double-booked; we're triple-booked. This is not good care." That evening, when the physician resigned, Dillard knew she had to do something drastic.

"We had tried every other type of scheduling and couldn't make anything work," Dillard said. "I can say without any hesitation that it is totally different now since implementing open access in January 2000."

Likewise, medicine had become a "job" for John Giannone, M.D., medical director of the Family Care Center in Deposit, N.Y., and an associate professor of clinical medicine at Upstate Medical College in Syracuse.

"I was swamped," Giannone said.

He couldn't stand hearing patients say that they tried to see him, but could not because he was booked. "There's such disappointment in their voices. They have a doctor, but he doesn't take care of them. I want to be someone's doctor," he said.

Now, after almost a year on open access, Giannone is becoming that doctor. He sees patients when they want to see him. And significantly, his patient satisfaction ratings have increased nearly 50 percent.

Patients are not the only ones who are happier with Giannone's practice. After working hard (and failing a few times) to cut his schedule backlog so that he could free it for open access scheduling, Giannone actually works fewer hours than he did before implementing the model. He has cut two hours a week out of his office schedule and eliminated evening and Saturday hours. Revenues at the practice have increased by 44 percent in the past year, and volume has increased by 22 percent.

Changing perceptions
Mark Murray, M.D., was in a busy group family practice with an average 55-day wait for nonurgent patients. "Patients with urgent needs could get in, but they couldn't get in to see their own doctors. And, there was no place to put a returning patient who couldn't wait 55 days. The system was frozen in the future," he said.

Murray started studying the scheduling processes of successful companies, including Toyota and Starbucks, and realized that medicine was doing it all wrong. About seven years ago, he started to develop a new model, which is now called open or advanced access. And today, he works full time consulting with practices and health systems worldwide about how to implement it.

"Basically, [it's a] do-all-of-today's-work-today model. The emphasis is on the word 'all,' " he said. "What happens is that all the urgent and nonurgent work is done today. Tomorrow is flexible because you don't have to hold or freeze appointments or carve out any space."

The new model worked like a miracle in his practice, Murray recalled. "We got done on time; there was a lot less work. The nurse who worked with us actually became free to help take care of patients because she didn't have to do triaging anymore. The amount of time that the receptionist took on the phone to make a decision was cut in half so it freed up people at the front desk. [They] were able to do more patient care services because they didn’t have to spend so much time on the phone arguing about appointments with patients," he said.

According to Murray, convincing his partners and staff to make the change wasn't easy. He had to teach them to think differently — to shift from the triage mentality that doctors and nurses are taught, to seeing all patients, regardless of need, on the day they call.

Implementing open access
True to Murray's experience, a practice has to change its way of thinking in order to begin the process of open access. "In [other scheduling] models, what we're doing is in order to protect today; we're pushing nonurgent demand out to the future. In the 'do-today's-work-today' model, the world and the mindset change: in order to protect tomorrow, we’re pulling all the work into today," Murray said. "You have to pull the work instead of push it."

According to Murray, applying open access is a step-by-step process. And each step is important for successful implementation.

Step One
Measure supply and demand — and find balance.
No model is going to work if demand is greater than the supply, so you must start by balancing the two. "People say I can't do it because my demand is bigger than my supply," said Murray. "Well, actually, what you're saying is that you can't do anything. Even in a saturated model, every day will put you further behind if you’re out of balance." Murray defined the saturated model as "the schedule that fills up today [with earlier] nonurgent demand, and we take urgent and pile it on top."

Step Two
Get the backlog out of the way.
Backlog reduction is not itself access improvement, but it is a necessary stage to get there. Treat backlog reduction as a controlled burn — look at the backlog and then look at how much additional work the staff can take on. If your time to the next available appointment is now four weeks, it will likely take that long to eliminate your backlog. Beware that it takes a fraction of that time to allow backlog to creep back into place.

Step Three
Eliminate appointment types.
Medical practices are notorious for breaking down appointments into types in an effort to control demand. "If you're going to do today's work today and calls are coming in, you don't need appointment types. All you need is an appointment," Murray said. "If you want to reduce the waiting time, which is what the access issue is all about, you have to reduce the [different appointment types] to the minimum number."

You may wonder how you can treat all appointments the same when a physical takes longer than treating a patient for an earache. Murray's response is that visits often change dynamically as they are progressing, particularly if patients have more than one problem to discuss. "It's the best system to have the same appointment length and adjust on the back end rather than trying to control it on the front end," he said.

Step Four
Develop contingency plans.
Contingency plans allow the staff to adjust when a doctor calls in sick or comes back from vacation, or something else happens to throw off the schedule.

Step Five
Reduce demand.
The best demand reduction strategy is to get doctors to see their own patients. "In my experience — working with multiple practices around the world — if doctors would just see their own patients, the demand would go down by about 15 percent," said Murray.

Step Six
Optimize the care team.
Make the best use of the physician's time by eliminating tasks from his schedule that the physician should not be doing, like appointment triaging that the nurses could be doing. Murray suggests elevating everyone on the team to the highest limits of their interest, expertise and licensure.

Step Seven
Review office efficiency.
Optimize efficient office flow in areas such as patient care, billing, appointments, etc.

Murray added that strong leadership, physician involvement and engagement of the entire team are also key to successful implementation of open access.

Beyond fear to success
Gordon Moore, M.D., a family practitioner in Rochester, N.Y., became so distraught about being crushed with the burden of the work and making slim — sometimes negative margins — that he left his group practice and struck out on his own. To Moore, "on his own" means being the only person in his practice — he answers the phone, does the billing and uses the open access model to schedule patients.
According to Moore, the fear of backlog reduction is overblown. "A lot of the fears around open access are unfounded. People wonder: 'Am I going to be overwhelmed by demand? All of a sudden my books are going to be clean, and I'm not going to have revenue.' Well those things are not the case because patients will love you for it, and you will be rewarded," Moore said.

Still, those who are successfully running their practices using the model agree it is no easy task to start or maintain, and like every scheduling model, it takes constant work and commitment. "One of our biggest challenges is keeping the schedule open," Dillard said.

Dillard added that despite the work involved, open access has been the best thing that ever happened to the practice, which has almost 20 practitioners. Due to the change in scheduling, the no-show rate has dropped from 21 percent to 14 percent; while 47 percent of the practice's patients surveyed used to report that they did not see the doctor of their choice for their appointments, only 6.5 percent have the same complaint today. The wait in the office has even diminished, and, while Dillard said that there continues to be room for improvement, about 60 to 70 percent of patients are seen within 15 minutes of their scheduled appointment time.