Advanced Access: How To Make it Work; Part A Catherine Tantau, BSN, MPA Tantau & Associates P.O. Box 179 Chicago Park, California 530-273-6550 ct@tantauassociates.com www.tantauassociates.com © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates 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. copyright Tantau & Associates

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copyright Tantau & Associates First things first… Measure Delay for routine appointments and elective procedures Set an Access aim Why the Gold Standard? The strength of organizational aim copyright Tantau & Associates

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 ©Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates 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! copyright Tantau & Associates © Tantau & Associates

1.Match Demand and Supply Daily…a review Make a decision… Carve-out or Advanced? Improve Continuity using panel information ©Tantau & Associates copyright Tantau & Associates

Demand Illness Burden of Population Mood and Attitude Continuity Practice Style Measure: True demand Demand Drivers: Panel Size, Case load, return visit intervals… © Tantau & Associates

Measuring Appt Demand Look at historical data?...no Worse case Scenario… Reassurance “real time” data Moment of Truth: Booking transactions

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

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?

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.

One SF Clinic’s Progress Balancing Demand, Supply, Activity copyright Tantau & Associates

Three Dimensions; Demand, Supply, Activity

How to Track… How long to track… Tic Marks vs Electronic tracking 4-6 weeks and then forever Separating Internal from External © Tantau & Associates

Tracking Appt Demand and Supply source: YKHC, Bethel Alaska

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.”

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

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

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

copyright Tantau & Associates 2. Reduce the Backlog Are we there yet? copyright Tantau & Associates ©Tantau & Associates

Good Backlog vs Bad Backlog copyright Tantau & Associates

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copyright Tantau & Associates Backlog Planning Assemble your team Develop a written plan Set two dates Who plays??? copyright Tantau & Associates

copyright Tantau & Associates Backlog Reduction No substitute for hard work, but… copyright Tantau & Associates

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!!!!! © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates Set Two Dates… Select a start date Select an end date © Tantau & Associates copyright Tantau & Associates

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” © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates Work Backlog As A Team Commit to continuity for appts Can someone else on the team manage this problem? Beware of Negative Reward © Tantau & Associates copyright Tantau & Associates

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? © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates 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! © Tantau & Associates copyright Tantau & Associates

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 © Tantau & Associates copyright Tantau & Associates

Extend The Visit Intervals Specific patient Specific diagnosis or care pathway Eliminate or combine certain return visits © Tantau & Associates copyright Tantau & Associates

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? © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates 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 copyright Tantau & Associates

copyright Tantau & Associates 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… © Tantau & Associates copyright Tantau & Associates

Hard Backlog Strategies Add daily capacity Where? When? How? Some customization is good. Be clear! copyright Tantau & Associates

Temporarily Add Capacity Not too much… Not too little… Just right! © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates 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 copyright Tantau & Associates

copyright Tantau & Associates 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! © Tantau & Associates copyright Tantau & Associates

copyright Tantau & Associates 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 copyright Tantau & Associates

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) copyright Tantau & Associates

Annotated Run Chart – Medical College of WI 1 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 copyright Tantau & Associates

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 copyright Tantau & Associates

YKHC Physical Therapy Reduction in Delays for Appointments Stopped serial Booking of returns No. of Days Date copyright Tantau & Associates

3. Decrease Appointment Types Times = Types Decrease variation -Increase flexibility Sorting and Matching Qualifying criteria Too complex? Never get it right!!!! © Tantau & Associates copyright Tantau & Associates

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 copyright Tantau & Associates

Queuing Options… The Bank copyright Tantau & Associates

copyright Tantau & Associates Grocery Store copyright Tantau & Associates

More appt types and times … More lines Less reliability More complexity Longer waits More fudging More Tension More chaos copyright Tantau & Associates

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 copyright Tantau & Associates

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 copyright Tantau & Associates

copyright Tantau & Associates 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.” copyright Tantau & Associates

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 copyright Tantau & Associates

copyright Tantau & Associates 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. copyright Tantau & Associates

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