Competency-based Curriculum: Advanced Access

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Advanced Access

Last updated at 11/02/2007 11:22:00 PM EST by Traci Nolte
Attachments:
STFM406OArevised2.pp t 37 KB
Baylor OASdownload.pdf 177 KB
Open Access Book Chapter Actual 0011.tif 790 KB

STFM Competency-based Curriculum:

Advanced Access Scheduling

 

George Valko, M.D.

Department of Family and Community Medicine

Jefferson Medical College of Thomas Jefferson University

 
 

Introduction

     Access to medical care is of paramount importance to patients and caregivers alike.  Access is more than just office visits, however, given that care can be delivered by phone, fax and the newer technologies of e-mail, text messaging or video streaming.  Access can also be delivered by group visits, home visits and by a team or chronic care model; many of these will be described by colleagues elsewhere on this website. 

     The goal of this section is to introduce the concepts of Advanced or Open Access Scheduling to residents, students and practicing physicians.  This section will also outline the ACGME competencies involved and give a sample curriculum for residents and students. The attachments of uploaded material, as well as the identified web sites and citations, will add more detail and an in-depth knowledge base for both teaching and practical purposes. The hope is that this site may stimulate interest  to all learners to develop methods to improve patient access to their practice sites.

 

ACGME Competencies

I.    Patient Care

By the time of graduation the resident will be able to:

  • Appreciate how a scheduling system may affect patient access to the office and therefore the patient care itself.
  • Have a working knowledge of  practice management issues as it pertains to patient care.
  • Improve office efficiency to make the most out of a patient visit.

II.   Practice-Based Learning and Improvement:

By the time of graduation the resident will be able to:

  • Specifically understand Advanced or Open Access Scheduling and how it differs from other scheduling systems.
  • Compare the advantages and disadvantages of Advanced or Open Access Scheduling for patient care and physician experience.
  • Analyze their own practice experience especially as it pertains to patient scheduling.
  • Understand scheduling terminology such as arrivals, no-shows, cancels, bumps and 3rd next available appointment.
  • How to measure scheduling concepts and understand how they affect their patients' care and office experience.
  • Understand continuity of care as it pertains to the patient and the clinician and how to measure it.
  • Assimilate this knowledge for use in their own career whether as teachers or clinicians.
  • Obtain and use information about their own population of patients and the larger population.

III.  Systems-based Practice:

By the time of graduation the resident will be able to:

  • Understand how decreased access to care in other professional practices will affect their own patient care.
  • Practice cost-effective health care by learning such techniques as "max-packing".
  • Begin to examine how to partner with other practices to improve patient access to care, especially specialty care.

 

Curriculum for Residents

Goals:

  • To develop a working knowledge of all aspects of Advanced or Open Access Scheduling and understand its role in office practice.
  • To stimulate the desire to become involved in all aspects of practice management.

Learning Objectives:

  • Characteristics of Advanced or Open Access Scheduling and and how it differs from other scheduling systems.
  • Knowledge of scheduling terminology such as arrivals, no-shows, cancels, bumps and 3rd next available appointments.
  • Measurement of key statistics (such as the above) and why it matters to a practice .
  • Benefits  and drawbacks of Advanced or Open Access Scheduling.
  • Continuity of care and what it means. 
  • Meeting RRC objectives for patient numbers and continuity of care.
  • Designing an Advanced or Open Access Scheduling System for a personal office.
  • Knowledge of practice management .
  • Obtain competency in practice-based learning and improvement.
  • Obtain competency in systems-based practice.

Learner characteristics:

  • Level: All PG years (and Fellows/new Attendings as needed).
  • Cultural Competency:  Residents will witness how Advanced or Open Access Scheduling allows all socioeconomic groups to have improved access to medical care.
  • Preassessment  methods:  residents will be assessed on knowledge of practice management in general and office scheduling in particular to better help future goals.

Teaching and Learning Activities:

  • Will be a part of practice management curriculum with emphasis on scheduling systems. 
  • Will use case studies and FAQ format.
  • Will have ample opportunity to work with the medical director, practice manager, and schedulers throughout the three years.

Support Services/Resources:

  • Lectures and reading materials per attachments and bibliography. 
  • Opportunities to attend national meetings.
  • Monthly practice patient and billing statistics reviews.
  • Membership in key practice committees.

Learner and Program evaluation:

  • Per resident faculty evaluation.

Faculty Development and Lifelong Learner

  • Residents will have exposure to practice management resources to and use their knowledge in their future practices.

 

 

 Curriculum for medical students:

Goals:

  • To develop a working knowledge of Advanced or Open Access Scheduling and understand its role in office practice.
  • Introduction to practice management.

Learning Objectives:

  • Characteristics of Advanced or Open Access Scheduling and how it differs from other scheduling systems.
  • Benefits and drawbacks of Advanced or Open Access Scheduling.
  • Introduction to practice management.

Learner characteristics:

  • Level: 
    •  Medical students in the 3rd and 4th year on required or elective clerkship
    •  Medical students in preclinical years at introduction to office practice lectures.
  • Cultural Competency:  the students will learn how open access allows all socioeconomic groups to have improved access to medical care.
  • Preassessment methods:  As part of introduction into the Family Medicine clerkship, students will be assessed on their knowledge of practice management in general and scheduling methods in particular.

Teaching and Learning Activities: 

  • Students will have at least one lecture at the beginning of the clerkship along with appropriate reading materials. 
  • Students will have an opportunity to work with  the medical director and/or practice manager.

Support Services/Resources:

  • As above.

Learner and Program Evaluation:

  • Learner evaluation will be a part of the end-of-clerkship examination material.
  • Program evaluation will be a part of the overall evaluation of the program.

 

 

Outline of teaching points:

I. Terminology:

  • Advanced Access Scheduling/Open Access Scheduling:
    • Both terms are used interchangeably and describe a type of office scheduling system that allows patients to be seen when they want or need to be seen.  At its core, these scheduling systems allow a practice to breakdown barriers to access to the office visit. Advanced Access usually includes good backlog whereas Open  Access is usually the same day appointments only. Attributed to the Institute for Healthcare Institute (IHI) but developed by several medical practitioners.
    • For simplicity, the term Advanced Access Scheduling will be used for the remainder of this document.
  • Traditional Scheduling Systems: 
    • Numerous exist, including the usual method of fully booking patients weeks and months in advance.  Many of these have policies to set aside time for sick visits; many also rely on overbooking so that patients may be seen in a timely fashion or to allow for no-shows or late cancellations.
  • Arrived Visit:
    • A patient who has checked in for an office visit, whether scheduled or as a walk-in.
  • Cancelled Visit:
    • A patient who has notified the practice that they will not be arriving to their scheduled visit. This cancellation may occur at any time up to the time of the scheduled visit.
  • No-show:
    • A patient who did not arrive for a scheduled visit and did not call to cancel that scheduled visit.
  • Bumped: 
    • An office visit that was cancelled by the practice or physician.
  • Walk-in:
    • A patient who literally walked into the practice for a visit without an appointment.
    • Many offices have an exclusive walk-in practice.
  • Visit types:
    • Denotes the main reason for the patient visit so a practice may allow "adequate" time for that visit. Examples include:
      • new patient physical
      • new patient sick
      • established patient physical
      • established patient sick
      • follow-up exam
      • gynecology exam
      • prenatal visit
      • pediatric well visit
      • pediatric sick visit
      • Sports Medicine
      • Minor surgical procedure
  • Urgent care:
    • Denotes a sick, ill or acute/emergency visit.  Usually does not refer to a patient who wants to be seen sooner for non-sick visits.
  • Routine care:
    • Usually means a well visit or a follow-up to a stable problem. 
  • Fit-in:
    • Also called squeezed-in or double- or over-booked, it denotes that a patient had to be added to an overburdened schedule, usually by begging to do so.
  • Capacity:
    • How many patients a practice or physician can truly see in a session.  Must calculate all arrived, no-show, bumped, cancelled and fit-in patients over a certain time period. 
  • Demand: 
    • The amount of patients who want to be seen over a certain time period.  Must calculate all arrived, no-show, bumped, cancelled and fit-in patients plus the amount of patients who called, written or walked in to make an appointment during that same time period.
    • Demand can be manipulated by max-packing and/or increasing the interval between office visits, or using an alternative means of a patient visit.
  • Hidden capacity: 
    • The arrived number of patients minus the no-shows, bumped and cancelled patients over a certain time period. This becomes apparent when the above calculations are reviewed.
  • Same-day appointments:
    •  Appointments made available for and on that same day.
    • Similar to walk-ins, but patients are given an appointment time. 
  • Continuity of care:
    •  Usually denotes that a patient identifies a physician as his or her doctor and that the physician identifies the same patient as his or her patient for a long term relationship. 
    • Can also mean that there is continuous care  by a physician for a certain problem.
  • Third next available appointment:
    • The industry standard that defines when an appointment is really available.  For example, the first or second appointment may be available within a day or two in a traditional scheduling system because of cancellations or no-shows, but the third next appointment may be weeks away.  In an advanced access scheduling system, the appointments are usually that same day or the next day.
  • Good Backlog:
    • In the advanced access scheduling system, this denotes the appointments made in advance or in the future because the patient or the physician wants it at that time, not because the practice could not see the patient that day.  For example, a physician wants a patient to come in for suture removal and wound check in 7 days, or a patient calls today but wants an appointment in two days from now because of transportation issues.
  • Bad Backlog:
    • Denotes the patient appointments made in the future because the physician or practice did not have appointments available to see those patients today, so work is put off until tomorrow and so on and so on ("Do today's work tomorrow").
  • Underground Economy:
    • Also called "Black Market" and refers to staff or physicians going outside of the Advanced Access Scheduling rules to fit patients into their schedules, usually because they don't like the scheduling system.
  • Max-Packing:
    • A term used to describe the practice of addressing as many problems or concerns of a patient a possible while that patient is in for a visit.  For example, a patient may just come in for a blood pressure check, but a physician will also address that patient's preventative care issues.  By maximizing the amount of issues addressed at one visit, it allows for a decreased number of future visits and therefore improves the available appointment times for other patients (reduces future demand).
  • Contingency Plans:
    • The planning that must take place to allow for an increase in demand.  For example, during the winter months the office may be busier because of the increased amount of illnesses.  Or, if a colleague will be away from the practice for an extended period of time due to vacation or illness.

 

 II.   Understanding the concept of Advanced Access Scheduling:

  • Advanced Access Scheduling is designed to improve patient access to care by eliminating many barriers to care which are the hallmark of a traditional scheduling systems and uncovering the "hidden capacity" within a daily schedule and reducing future demand. These barriers include:                        
    • Schedules booked weeks or months in advance
      • Patients must make an appointment far in advance or beg to be "fitted-in" sooner.  The original patient problem may have resolved by the time the appointment arrives or the patient may have forgotten the appointment leading to a "no-show"  or cancelled appointment.  If that same patient then tries to reschedule, it may be several more weeks or months to get a next appointment. If the patient is a "no-show", then that patient appointment slot may not be filled.  Offices compensate for this by overbooking, which will present its own problems. 
      • By having the bulk of the appointments open for the same day or next day with  Advanced Access Scheduling, many more patients may be accommodated when they want or need to be seen and less likely to cancel or no-show.
    • Multiple visit types
      • Typically, offices have multiple visit "types" that they believe will help the day run more smoothly. If a patient calls to be seen for a blood pressure follow-up, but the only visit types available that day are gynecology, pediatric, new patient or acute appointments, then that patient must be scheduled on another day.
      • If the visit type is limited to only a few types, such as new patient and established patient, than any patient can be seen for whatever problem or concern and whether for a well or sick visit. This is one way to uncover hidden capacity.
    • Variable visit times: 
      • Offices usually set aside time slots for various visit types such as new patient visits, gynecology care or others which may hinder access.  If a patient must be seen for a simple blood pressure check which will take five minutes, but the only appointment available is for a 45 minute new patient appointment, that patient will be scheduled for another day.
      • Under Advanced Access Scheduling, all the times to are limited to one or two time periods.  Any patient may be seen for what ever problem in any time slot.  Over the course of a day, the times will average out.
    • Distinction between urgent and routine care
      • Many offices have "carve-out" time for which sick patients are seen.  If an urgent but non-sick problem arises such as a sports physical exam, that patient cannot be seen that day.
      •  Advanced Access Scheduling eliminates the distinction between urgent and routine care so that any patient who wants or needs to be seen will be seen ("Do today's work today"). 
  • The ideal is for capacity and demand to be in equilibrium.  Along with improving access, the office may want to improve the times when the physicians are available, insure that staff and physicians are on time or add ancillary help to handle items for which a physician does not need to do.  This will further  increase the capacity of the practice to see more patients. 

 

 III.  Benefits of Advanced Access Scheduling:

  • Many benefits are attributed to Advanced Access Scheduling.  A few of these include:
    • Patient satisfaction:
      • An "AH-HA" moment occurs when a patient calls for a routine visit and expects to be seen a month from now but is given an appointment the same or next day
    • Improved timeliness of patient care:
      • Under the traditional scheduling system, if a patient has waited a month for an appointment and then for whatever reason misses that appointment, it will take another month to get another appointment. Under Advanced Access Scheduling, that patient will get an appointment the same or next day.
    • Increased arrived patients:
      • If a patient makes an appointment for the same day or next day, that patient is more likely to keep that appointment.  Therefore, the practice has less "no-shows" or late cancellations, a more fully booked schedule, and the work is done today. And, future appointments are available to other patients. 
    • Decreased no-shows:
      •  A patient is more likely to keep an appointment made the same day or within a few days.  A practice may manipulate these no-shows by increasing how far in the future the appointment is made; the further out the appointment is made, the more likely the patient will cancel or no-show.
    • Improved office efficiency:
      • If a physician must cancel an appointment under the traditional scheduling system, there is usually a lot of staff time involved to call and reschedule those patients, let alone find a place in the schedule for a timely appointment.  Under Advanced Access Scheduling, there may not only be fewer patients to reschedule, but those patients may call themselves to reschedule at the next physician office hours and in a more timely fashion.
    • Improved financial picture:
      • If more patients arrive to the practice, then more patients will be billed.  If the physician is max-packing, then the billing level should be higher. If there is a HMO population, then with the improved efficiency and resultant improved capacity, more patients can be signed. 

 

IV.  Planning a major change in office practice/office redesign or improvement with emphasis on Advanced Access Scheduling:

  • Leadership:
    • Leadership is needed because any change to "the way things are always done" is a threat in itself. To create a change as drastic as advanced access over the traditional way of scheduling patients that has been done for decades requires leadership to believe in the change, be bold enough to insist on the change and to be resolute to follow it through from implementation to the steady state.
  • Planning: 
    • Involves setting goals and objectives. For example, a goal of a practice with multiple providers may be to see all of its patients whenever they want or need to be seen.  This would then lead to other physicians in the practice to see patients other than their "own" patients if an opening occurs.
    • Or the goal may be have the patients to see their "own" physician when they want or need to be seen which would entail a process for that to happen.
    • Per IHI and others, "every system is perfectly designed to achieve exactly the results it gets". 
  • Education: 
    • Education of staff, physicians and patients is paramount in any significant change of office policy so a process to do this must be started at the onset.
    • Education must also be to follow the system:  as above, the underground economy can undermine this or any scheduling system.

 

 

V.  Outcomes measurements: 

  • A good time to take the "pulse" of the practice is during the planning stage of change to Advanced Access Scheduling.  This will not only give an idea of what is going on now, but will give a benchmark for measurements in the future.  Measurements will include:
    • Patient satisfaction:
      • With the time it takes to get an appointment with the practice or the patient's physician.
      • The phone system.
      • The ancillary staff.
      • The wait until the patient sees the physician after arrival to tho practice.
    • Continuity of care:
      • Percentage of arrived patients that are the physician's own patients.
      • Percentage of time the patient sees his/her own physician.
      • Ramifications for RRC requirements for residents and work well in Advanced Access Scheduling.
    • Arrivals, no-shows, cancellations, bumps:
      • Allows to document improvement and calculate hidden capacity. 
    • Financial picture:
      • As it pertains to the amount of revenue that is lost  with no-show appointments.
      •  Also measure E/M coding, levels of visits.
    • Physician satisfaction:
      • Is the physician satisfied with the current scheduling system? Or, especially if in a teaching program, must a physician take time out of teaching or research activities to make up patient numbers because of patient no-shows during his/her regular office hours?  With Advanced Access Scheduling, physicians are busy during their patient hours but are easily able to see ther required amount of patients.
      • This is true also for RRC requirements for resident patient numbers.

 

 

VII.  Resources:

  • See Attachments:
    • STFM4060Arevised = Power Point presentation at STFM Annual Conference, May 2006, San Francisco CA which shows an sustained four year improved productivity and financial picture using Advanced Access Scheduling.
    • Baylor Download = article by Steinbauer, et al cited below describes how Baylor started Advanced Access Scheduling.
    • Open Access Book Actual = book chapter by Valko cited below is a "how-to"  to start Advanced Access Scheduling.
  • Articles and Publications:
    • Berwick SM. Escape Fire:  Lessons for the Future of Health Care.  New York, NY: The Commonwealth Fund; 2002.
    • Kahn NB with the Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community.  Annals of Family Medicine. 2004;2:S3-S32.
    • Kennedy JG, Hsu JT. Implementation of an open access scheduling system in a  residency training program.  Family Medicine. 2003;35:666-670.
    • Maeseneer JM, DePrins L, Gosset C, Heyerick J.  Provider continuity in family medicine.  Ann Fam Med. 2003; 1:144-148.
    • Murray M, Tantau C.  Same-day appointments: exploding the access paradigm.  Fam Pract Manag. 2000;7:45-50.
    • Murray M. Answers to your questions about same-day scheduling. Fam Pract Manag.  2005;12:59-64.
    • Murray M, Berwick DM.  Advanced access: reducing waiting and delays in primary care. JAMA. 2003:289:1035-1040.
    • Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC.  Continuity of primary care: to whom does it matter and when? Ann Fam Med. 2003;1:149-155.
    • OHare CD, Corlett J.  The outcomes of open-access scheduling. Fam Pract Manag. 2004;11:35-38.
    • Scherger JE. The end of the beginning:  The redesignimperative in family medicine. Fam Med. 2005;37:513-516.
    • Steinbauer JR, Korell K, Erdin J, Spann SJ.  Implementing open access scheduling in an academic practice.  Fam Pract Manag. 2006;13:59-64.
    • Valko GP: Open Access Scheduling.  practicing medicine in the 21st century. American College of Physician Executives; Nash et al, Editors. October 2006.
  • Websites:
    • www.ihi.org
      • The website for the Institiute for Healthcare Improvement.
    • www.va.gov/oaa/teaching_tools/default.asp
      • Adapted from Mark Murray, MD, MPA and Marie W Schall and the Institute for Healthcare Improvement 2001, this website offers teaching case-studies  for its internal medicine clinics in the Veterans Administration healthsystem. (Advanced Clinic Access Initiative, National SubCommittee on Academic Environments in conjunction wiht the Office of Academic Affairs and the Officeof the VA Deputy Undersecretary of Health for Operations and Management). 

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