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Advanced Access:How To Make it Work;Part A
Catherine Tantau, BSN, MPA
Tantau & AssociatesP.O. Box 179
Chicago Park, California530-273-6550
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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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High Leverage Changes forAccess Improvement
1. Match Demand and Supply Daily
2. Reduce Backlog
3. Decrease Appointment Types and Times
4. Develop Contingency Plans
5. Reduce Demand for Visits
6. Optimize the Care Team
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Sequencing for Advanced AccessMany 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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1.Match Demand and Supply Daily…a review
Make a decision…
Carve-out or Advanced?
Improve Continuity using panel
information
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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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Measuring Appt Demand
Look at historical data?...no Worse case Scenario… Reassurance “real time” data Moment of Truth: Booking
transactions
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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
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Appointment Demand Worksheet
Date: ____________
Care Unit 3
Patients calling today, requesting appt, regardless of day appted to
(External)
Walk-Ins today
appted
(External)
Deflections,
eg UCC, if trackable
(External)
Return appts booked today as pts leave today’s appt.
(Internal)
Total Demand
Optional; Pts
turned away, not booked. Do not
add into Demand
Provider
A
Provider
B
Provider
C
Provider
D
Total
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Measured demand
Calls for visits
Other external demand
Internal demand
# appt per day
Monday 44 2 29 75Tuesday 34 5 25 64Wednesday 29 8 35 72Thursday 30 3 18 51Friday 37 1 31 69
Provider capacity
# appt per day
MondayTuesdayWednesdayThursdayFriday
VISIT RATEVisits per hour
Provider A 3Provider B 3Provider C 2.25Provider D 3Provider E 3Provider F 3
HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AMProvider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875
0
10
20
30
40
50
60
70
80
MondayTuesdayWednesdayThursday Friday
Appointment Demand
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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?
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Appointment Supply Worksheet
Week of:____________
Provider
A
Mon
Tues
Wed
Thurs
Fri
Sat
Total
Supply
Provider B
Provider
C
Provider
D
Total
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Measured demand
Calls for visits
Other external demand
Internal demand
# appt per day
Monday 44 2 29 75Tuesday 34 5 25 64Wednesday 29 8 35 72Thursday 30 3 18 51Friday 37 1 31 69
Provider capacity
# appt per day
Monday 70.125Tuesday 61.5Wednesday 87Thursday 58.875Friday 84
VISIT RATEVisits per hour
Provider A 3Provider B 3Provider C 2.25Provider D 3Provider E 3Provider F 3
HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AMProvider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875
Appointment Capacity versus Demand
0
10
20
30
40
50
60
70
80
90
100
Monday Tuesday Wednesday Thursday Friday
Provider capacity Measured demand
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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.
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One SF Clinic’s Progress Balancing Demand, Supply, Activity
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Appointment Activity Worksheet
Week of:____________
Provider
A
Mon
Tues
Wed
Thurs
Fri
Sat
Total
Activity
Provider B
Provider
C
Provider
D
Total
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Three Dimensions;Demand, Supply, Activity
Average Supply & Demand December 12 - July 7
3 Appointments Per Hour
7975
60
73
82
63 62
5551 49
2732
24
33 35
0
10
20
30
40
50
60
70
80
90
Monday Tuesday Wednesday Thursday Friday
Supply Demand Patients Seen
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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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Apr-05 May-05 J un-05 J ul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 J an-06 Feb-06 Mar-06 Apr-06 Average M T W TH FDemand 197 186 174 159 161 159 156 216 211 168 146 176 Demand 261 240 235 208 184Supply 171 179 195 179 201 176 164 192 174 150 118 173 Supply 193 190 162 195 175
S&D Average Weekly Averages
Supply & Demand
0
50
100
150
200
250
300
350
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Day of the Month
Demand Supply
Average Weekly Supply and Demand
0
50
100
150
200
250
300
M T W TH F
Demand Supply
Family MedicineSupply & Demand Daily Average by Month
0
50
100
150
200
250
Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average
Demand Supply
Tracking Appt Demand and Supply source: YKHC, Bethel Alaska
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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.”
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If Demand is Greater than Supply
1. Work harder ?2. Delay the work ?3. Buy more supply ?4. 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
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Identify source of Demand and ask, “Why?” Internal External Discontinuity Single issue visits to ramp up visit
count? Bumping Delays and defensive booking Growth
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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 Backlog2. Reduce the Backlog
Are we there yet?
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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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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 &
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Set Two Dates…
Select a start date
Select an end date
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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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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!© Tantau & Associates copyright Tantau &
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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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Extend The Visit Intervals Specific patient
Specific diagnosis or care pathway
Eliminate or combine certain return visits
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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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Third next appointment -PT
0
5
10
15
20
25
30
35
40
RH
KH
HJ
Sometimes a small change can make a big difference…YKHC Physical TherapyReduction in Delays for Appointments
Date
No. of Days
Stopped serialBooking of returns
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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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Hard Backlog Strategies
Add daily capacity
• Where?• When?• How?• Some customization is good.• Be clear!
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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
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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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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)
J onKoping Dept of Internal Medicine Neurology
0
50
100
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Day
s__r
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Annotated Run Chart – Medical College of WI
Visit Access -3rd Next Available Appt
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9/26
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1/05
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/05
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9/05
Day
s
New Appts. F/U Appts.
12 3
1. Extended visit intervals based on actual availability and clinical need2. Summer vacation with no contingency plans3. New provider began to see patients, Dec. 1
1
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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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Third next appointment -PT
0
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10
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RH
KH
HJ
YKHC Physical TherapyReduction in Delays for Appointments
Date
No. of Days
Stopped serialBooking of returns
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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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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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Queuing Options… The Bank
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Grocery Store
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More appt types and times … More lines Less reliability More complexity Longer waits More fudging More Tension More chaos
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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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“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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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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