1. Advanced Access: How To Make it Work; Part A
Catherine Tantau, BSN, MPA
Tantau & Associates
P.O. Box 179
Chicago Park, California
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Objectives…
Learn how to balance Demand and Supply using practical, tested approaches
Leave with an understanding of the basic elements of an effective Backlog Reduction plan to close the gap between current delays and your access goals.
Recognize the value of, and strategies for, simplifying appointment types and times.
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First things first…
Measure Delay for routine appointments and elective procedures
Set an Access aim
Why the Gold Standard?
The strength of organizational aim
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5. High Leverage Changes for Access Improvement
Match Demand and Supply Daily
Reduce Backlog
Decrease Appointment Types and Times
Develop Contingency Plans
Reduce Demand for Visits
Optimize the Care Team
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Sequencing for Advanced Access Many options; one example of a tested path
Set Access Aim
Measure delay for routine appt for each provider
Measure Demand and Supply
These are not necessarily linear, consider parallel processing…
Empanel patients with a PCP and promote Continuity
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 at least monthly
Celebrate successes and failures!
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7. 1.Match Demand and Supply Daily…a review
Make a decision…
Carve-out or Advanced?
Improve Continuity using panel information
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8. Demand Illness Burden of Population Mood and Attitude Continuity
Practice Style
Measure: True demand
Demand Drivers: Panel Size, Case load, return visit intervals…
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9. Measuring Appt Demand Look at historical data?...no
Worse case Scenario…
Reassurance
“real time” data
Moment of Truth: Booking transactions

10. Demand
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 if result in appt booked
+ Deflections we can count? (UCC ?)
Internal
+ Returns booked today as pt leaves
Total Demand

13. 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
Process of Supply…
What is the work?
Who does the work?
What can we try doing differently?

16. Activity; the 3rd 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.

17. One SF Clinic’s Progress Balancing Demand, Supply, Activity
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19. Three Dimensions; Demand, Supply, Activity

20. How to Track… How long to track…
Tic Marks vs
Electronic tracking
4-6 weeks and then forever
Separating Internal from External
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21. Tracking Appt Demand and Supply source: YKHC, Bethel Alaska

22. 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.”

23. If Demand is Greater than Supply
Work harder ?
Delay the work ?
Buy more supply ?
Do the work differently !!! …test….
Shape Demand
Eliminate duplicate visits
Care Team development; leverage the work
Extend visit interval
Promote Continuity
Max Pack
Simplify Appt types and times
Nurse Appts, phone appts, group appts.
Improve Access to reduce No Shows and capture that Supply
Spread

24. Identify source of Demand and ask, “Why?”
Internal
External
Discontinuity
Single issue visits to ramp up visit count?
Bumping
Delays and defensive booking
Growth

25. If Supply is greater than Demand…
Opportunities
Backlog reduction easier
Growth
Challenges
Over supplied if growth not possible
Financial impact

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2. Reduce the Backlog
Are we there yet?
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27. Good Backlog vs Bad Backlog
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Backlog Planning
Assemble your team
Develop a written plan
Set two dates
Who plays???
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Backlog Reduction
No substitute for hard work, but…
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31. Backlog Plan: Smart Strategies
Work backlog as a team
Look ahead at the schedule
Maximize the 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!!!!!
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Set Two Dates…
Select a start date
Select an end date
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33. Do Increasingly More Of Today’s Work Today
Commit to it!
Don’t add to the end of the queue
Loosen the criteria for “today”
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Work Backlog As A Team
Commit to continuity for appts
Can someone else on the team manage this problem?
Beware of Negative Reward
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35. Look Ahead At The Schedules
Check for duplicate visits and referrals…comb the schedule.
Will a telephone call suffice? Phone appts? SF General Family Medicine testing
Can more be done at today’s visit to eliminate a future visit?
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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!
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37. Maximize Visit Efficiency
Increase the value of the face-to-face clinician/patient time
Eliminate distractions / interruptions
Leverage the providers time (OE)
Do more with some visits
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38. Extend The Visit Intervals
Specific patient
Specific diagnosis or care pathway
Eliminate or combine certain return visits
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39. 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?
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Sometimes a small change can make a big difference…YKHC Physical Therapy Reduction in Delays for Appointments
Stopped serial
Booking of returns
No. of
Days
Date
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Hard Strategies
Temporarily add daily capacity
How much, where, when…
Do increasingly more of today’s work today…add less to end of queue
Identify team members roles and responsibilities…
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42. Hard Backlog Strategies
Add daily capacity
Where?
When?
How?
Some customization is good.
Be clear!
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43. Temporarily Add Capacity
Not too much…
Not too little…
Just right!
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Thoughts To Consider…
Promote team communication…daily huddles, standing agenda item.
Collect data, analyze it, talk about it, share it.
Gain commitment
Support the team
Motivate the staff
Celebrate
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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 a little better or worse!
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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
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47. Example from Swedish Health Care System
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)
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48. Annotated Run Chart – Medical College of WI1 1 2 3
Extended visit intervals based on actual availability and clinical need
Summer vacation with no contingency plans
New provider began to see patients, Dec. 1
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49. PDSAs: The Wisconsin Experience
1. All patients leave clinic with an appt based on real supply-
looked at 3rd next, extended visit intervals where appropriate, considered phone follow-up in place of visits, need for tailored follow up plans
2. Every patient leaves with a follow-up plan
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50. YKHC Physical Therapy Reduction in Delays for Appointments
Stopped serial
Booking of returns
No. of
Days
Date
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51. 3. Decrease Appointment Types
Times = Types
Decrease variation
-Increase flexibility
Sorting and Matching
Qualifying criteria
Too complex? Never get it right!!!!
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52. Standard Appointment Lengths
Queuing; Grocery Store vs Bank
Leveling for all the system
See work in the whole system
- Triage for appts
What patients tell the agent
What staff tell the lab!
Likelihood of staying on time
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53. Queuing Options… The Bank
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Grocery Store
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55. More appt types and times …
More lines
Less reliability
More complexity
Longer waits
More fudging
More Tension
More chaos
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56. Multiple Times = Multiple Types
3 types or 3x4 types????
Different definitions for each PCP?
Customization difficult to manage
New providers; hold every other appt rather than create new types
Over booking and double booking reduce actual time for appt
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57. Gillette Children’s Hospital
“I love my schedule template. I just can’t remember the last time I had a day when patients were scheduled
that way!”
-Steven Koop, MD
Gillette Children’s Hospital
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Common issues….
Caps on certain types of appts
WCC, WWP, Physicals, others?
Squeezing 8 hours of work into a 6 hour day; “No more appts booked after 3 pm because we always run behind.”
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59. Best examples in Primary Care
One, average appt length
Next best: all “shorts” with a few well defined “longs”
Scooping 2 shorts to create longs
Idea!
Measure actual face to face time with different appt lengths
Test 1 session with 1 PCP with an average appt length
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So, what’s next????
Best ideas…..
Plans to meet….
Organize Backlog Plan….
Simplify appt types, times, templates
Keep measuring Delay, Demand, Supply and Activity
What else…..?
More to follow….the rest of the strategies.
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