Re-engineering Your Practice

You mean I can see the doctor today?

Same-day scheduling is a challenge to implement, but groups that have adopted it say patients are happier and the doctors are more productive.

By Deborah A. Grandinetti
Senior Editor

Same-day scheduling has done more than give Dean Health System FP David J. Okada satisfied patients. It has also given him more of a home life. That's because the Oregon, WI, physician, part of a suburban three-doctor practice within a larger multispecialty group, can now finish his dictation, prescription refills, and paperwork between appointments. These days, he typically leaves work by 6 pm, instead of between 7 and 8.

Meanwhile, patients are so pleased that they're telling friends how they can usually get an appointment the day they call. As a result, the practice is attracting many new patients within its highly competitive market.

The same phenomenon is reported by pediatrician Jill A. Swanson, section head of community pediatric and adolescent medicine for the Mayo Clinic in Rochester, MN. "We've seen growth in the number of patients," says Swanson. "The patient satisfaction is incredible."

What pleases her about the system is that it greatly increases the odds that physicians will see their own patients, instead of forfeiting them to other group doctors, the urgent care center, or the local emergency room. "There's been better continuity of care," says Swanson. "This is a much more gratifying way to practice."

As you might have guessed, same-day scheduling (also called "advanced access" or "open access" scheduling) involves more than just the appointment calendar. It's really a form of practice re-engineering that will force you to rethink everything from staff roles to how exam rooms are stocked. At its most basic, however, same-day scheduling is a commitment to starting the day with mostly open appointment slots. This way, physicians can see all the patients who want to be seen that day without double-booking them. From this simple premise flows a lot of good—clinically, operationally, and financially—say physicians and administrators who use the system.

For starters, same-day scheduling boosts physician efficiency. "Doctors say it's easier to deal with a patient on the day he calls than a patient whom they've put off," says Marnee Iseman, director of downtown primary care for Virginia Mason Medical Center in Seattle. Doctors don't have to spend time apologizing to the patient for the lengthy wait, or studying the chart of a colleague's patient so they know how to proceed. There's also much less chance that an acutely ill patient will be turned away because the schedule is full. "When people are ill, that's when they most want to see their own doctor," says internist J. Frederick Brodsky, chief of the Group Health Cooperative primary care office at Sauk Trails Health Center in Madison, WI. "It builds trust. Patients know that you'll be there when they need you." Moreover, getting the patient in sooner may allow the physician to intervene earlier in an illness, which can reduce the need for follow-up visits.

When the roles of nurses and other staffers are redefined under same-day scheduling, they can help the physician improve his efficiency. Triage nurses no longer have to spend time on the phone figuring out what type of appointment to give a patient, because this system greatly simplifies the kinds of appointment available. Swanson's practice, for instance, has reduced its appointment types from 60 to just two: same-day and next-day (which refers to any day beyond the current one).

That and many smaller changes prompted by the switch to this scheduling system have enabled the practice to increase its same-day appointments from 20 percent of the day's schedule to between 40 and 60 percent, depending on the season. The wait for a well-baby exam has gone from 60 days to between zero and 20 days, depending on the physician or nurse practitioner.

The system has also reduced the no-show rate. Iseman says that the number of patients who don't keep appointments has decreased by half since Virginia Mason Medical Center introduced advanced access in some of its practice sites. This makes space for new patients and assures the practice it can count on revenue from patients who book appointments.

If you're worried about being overwhelmed by patients, bear in mind that no more than 70 to 80 percent of your visits will be same-day because of follow-ups and the preferences of some patients for later appointments. Experience shows that about 0.8 percent of the average patient panel will visit on any given day.

Expect variations in the number of patients who want to be seen immediately. Typically, your case load will range from 18 to 27 patients per day under advanced access, say experts. The variation will tend to flatten out after a year, provided your panel isn't too big.

How the system solved one practice's access problem

Back in 1993, FP Mark F. Murray and RN Catherine Tantau, the team leaders at a six-physician Kaiser Permanente clinic in Roseville, CA, were concerned about patient access. At the time, the practice's average wait for a physical was 55 days, but it could stretch as long as three months.

"Our adult medicine department was in trouble," says Murray. "Demand seemed insatiable, the schedule was full, doctors were not happy, and the young, healthy patients were leaving us because of the delays."

This was a situation Kaiser couldn't afford to ignore. At the time, growth had stagnated, and Kaiser was no longer able to best its competitors on price, says Murray. Member surveys showed that access was the key determinant for consumers choosing a health care provider. So he and Tantau set out to improve theirs.

They changed the guidelines for urgent care, tried an urgent care clinic, and experimented with a telephone triage service. But they found that money spent on triage nurses was wasted, because patients who were discouraged from seeking appointments invariably showed up the following week.

A "carveout system," which allotted up to half of each day for urgent care appointments, worked no better. A patient who called without an urgent complaint would be put at the end of the queue, which might mean she'd have to wait a month or more. If her problem was deemed urgent but she couldn't get in that day, she'd be told to call back on the day she could come in. That irritated patients, and it meant the staff had to handle the call twice, says Murray.

Ultimately, the carveout "solution" was scrapped, and Murray and Tantau hit on the almost unthinkable idea of offering same-day appointments for every problem, urgent or not.

For the next six weeks, the practice focused on working down the appointment backlog. Physicians put in more hours so they could see patients as soon as possible, rather than at the end of the appointment line. Murray and Tantau also figured out how physicians could make the most of each visit, tackling multiple problems so patients wouldn't have to be seen quite so often. That would open up appointment slots, too.

Once the backlog was cleared, and the practice could offer same-day access, "magical things happened," says Murray. "The wait time for a routine appointment went to zero. We no longer had to hold appointments aside for physicals. And we discovered that nobody could beat our access."

Kaiser gradually expanded the system to all 15 of its adult medicine sites in northern California. Patient satisfaction shot up, the number of visits per patient dropped by an average of 7 percent, and the regional Kaiser operation eliminated most of its urgent care clinics, says Murray.

Since then, he and Tantau have taught the system to more than 150 groups worldwide. About 40 practices in the US are now using it, according to Murray. Among them are most of the two dozen groups now involved in practice re-engineering under the aegis of the Boston-based Institute for Healthcare Improvement.

Is same-day scheduling for you?

Any full-time physician can make same-day access work, say Murray and Tantau. While it's especially advantageous for fee-for-service practices that want to expand, it can also boost the revenues of practices with capitated contracts.

While most of the practices that use same-day scheduling are medium-sized to large groups and their subunits, the physicians who are using the system feel that a small practice could implement it, too.

"This is not so different from the way old-time physician offices operated," says Fred Brodsky of the Group Health Cooperative staff-model HMO. But he warns that same-day scheduling won't work if demand is too great. "If the demand is 1,000 patients a day, but you can only accommodate 500, you can slice and dice this system any way you want, and it still won't work," he says.

The trick is to measure demand accurately. "That's different from how many patients you currently see per day," says Brodsky. "For three weeks, we tracked how many people were calling, and found the number was manageable, given our provider capacity. That gave us confidence we could do this." They needed that assurance, he says, because Group Health's low copay and rich drug benefits tend to encourage frequent patient visits to the Sauk Trails clinic.

Marnee Iseman from Virginia Mason Medical Center has learned to calculate demand by counting several measures in addition to the number of patients who call. The practice also tracks how many patients are scheduled for a return visit, how many are bumped to the end of the queue, how many are deflected to urgent care, and how many walk in without an appointment.

"We made the mistake of beginning this process before we really understood what our demand was," she says. "It took us a month to figure out why scheduling was still chaotic."

If you find that demand would outstrip capacity, you don't necessarily have to hire more physicians or midlevel providers. There may be ways to reduce demand without compromising patient care, advocates say. For example, the Dean Health System "started advocating flu shots and installed a flu hotline for patients," says administrator Barb Boushon. "We also looked to see whether the return intervals for physicals were appropriate, or whether they could be extended."

Why implementation is so challenging

Same-day scheduling is difficult to implement for several reasons. One is that you may encounter resistance from your colleagues when you first propose the system. "Physicians are groomed to believe that a long backlog is a sign of prestige," says Iseman. "Implementing this scheduling system is like taking their security blanket and burning it."

Another difficulty is that it takes a full year to work out the bugs, because certain disease trends change with the seasons, notes Tantau. "But you'll start to feel the benefits far in advance of that," she says. How long in advance will depend on how many weeks or months it takes to work down the backlog.

Doing this requires setting a target date, after which there will be no backlog. Because your appointment schedule needs to be clear on that target date, your practice will need to fit in all the patients who call during the interim period. Obviously, that requires physicians—and perhaps staffs—to work longer hours. But it may not entail additional expense.

"Initially, we tackled the backlog with no additional resources, but I don't necessarily recommend that," says Tantau. "It's a good idea to provide doctors and staff with meals and some amenities. Ask them what kind of support they'll need. Additional support can be helpful, because you want to make sure patients don't substitute a long wait in the office for a long appointment wait. We found that doctors tend to be amazingly modest in their requests. They might say, 'During those interim weeks, we want an additional medical assistant or receptionist or nurse.' Rarely do they ask for all three. Of the groups contacted by Medical Economics, only Group Health Cooperative provided incentive pay to compensate physicians for working more hours during the transition period. "This made it more palatable," says Brodsky.

The Mayo Clinic "did it on pizza and cookies," says Swanson, since the group had no resources budgeted to pay its salaried doctors more for this purpose. It took Mayo's physicians three to six months to work down the backlog, she says. They added hours on four weeknights when the clinic would normally be closed, put in more time during the typical workday, and tried to pack as much as possible into each appointment so patients wouldn't have to return as frequently.

At Dean Health System, the staff didn't work overtime—thanks to a very creative supervisor, says Boushon—but physicians put in an additional half-day a week. FP David Okada says it took him four months to reduce the wait for routine physicals from five months to one, but much longer to whittle it down to a week. What made that transition bearable, he says, were frequent updates on how much backlog he had cleared.

Physicians and support staff typically use the transition period to experiment with ways to work more efficiently. They scrutinize how patients cycle through the office, how paperwork is handled, and whether exam rooms are stocked with the requisite equipment and supplies. Dean Health Systems, for instance, had physicians keep track of how many times they had to leave an exam room to get supplies. Now the staff makes sure that the rooms are well-stocked, says Boushon.

Practices also study how to make better use of staff members, so physicians don't have to perform tasks that are easily handled by someone else. This allows doctors to work faster.

Another favorite same-day strategy, called "maxpacking," encourages physicians to pack as much into a visit as possible. Let's say the patient comes in with an acute illness, but is scheduled for a general exam the next week. The physician might say, "While you're here, let's get that exam done, so I can save you a visit."

Results—and continued challenges

At Dean Health System, which began experimenting with same-day scheduling in mid-1998, the results have been gratifying, says Boushon. The clinic involved in the pilot has increased its patient count by over 10 percent, and its income by over 20 percent. Meanwhile, "the waiting room is nearly empty, because patients are being seen on time," she adds.

Mayo Clinic's Jill Swanson says that the effort expended to implement same-day scheduling has "made a significant difference. I will never approach the access problem in the same manner as we did before." She found it "most enlightening," for example, to look "not at what we supplied, but at patient demand. Now we can better predict what capacity we need to provide."

But that's not to say same-day scheduling has solved every problem, or that it hasn't created new ones. Swanson, for instance, has noticed that as her providers ramped up productivity, they were slowed by other departments that hadn't. Virginia Mason's Marnee Iseman is still struggling with the challenge of how to apportion new patients equitably, so that they don't interfere with physicians who are still working down their backlogs or overburden the most efficient physicians. There's also the challenge of maintaining the changes in practice style, so the backlog doesn't reappear.

Meanwhile, Iseman says, patients have started a different kind of argument with staff. "When they call for an appointment, they'll say, 'What do you mean—today? You can't possibly mean today!' When they realize they've heard it right, they're delighted," says Iseman.

The economic impact of same-day scheduling

Can changing the scheduling system actually boost practice profits? FP Mark Murray and RN Catherine Tantau, co-developers of advanced-access scheduling at Kaiser Permanente, claim that it can.

Here's an example: Strong Health System, a Rochester, NY, integrated delivery system, has introduced advanced-access scheduling at four practices since February 1999. Three are primary care practices; the other is an ophthalmology clinic. The experiment appears to be a success. Each of the two physicians in one internal medicine practice is attracting an average of 10 to 15 new patients a month, and the ophthalmology clinic has registered a 17 percent increase in revenue. Based on these encouraging results, Strong has decided to spread the approach to other practices in its network. A study done for the system estimates that same-day scheduling could expand Strong's practices by up to 40 percent.

Dean Health Systems, similarly, found that advanced-access scheduling enabled its three-physician Oregon Clinic (in Wisconsin) to increase income by 20 percent in one year. Murray says that physicians and other providers at one southern California group were able to boost fee-for-service revenues by an average of 30 percent per provider. "There was growth in one clinic that hadn't shown growth for five years," he said.

Practices that use same-day scheduling achieve results like this partly because physicians have to work more efficiently in order to open up the appointment calendar. Once physicians learn how to pack more into a single visit, utilization rates drop by as much as 10 to 25 percent, says Tantau. That creates room for new patients. Practices that use this system have been reporting average panel-size increases of 5 to 6 percent, adds Murray.

In fee-for-service practices, these new patients are the ones who tend to generate the most robust relative value units. "The money isn't made on visit 11 or 12, but on visit 1 or 2," observes Murray. "That's when patients need procedures, surgeries, MRIs, and hospital consults."

Volume alone, he says, does not equal profitability. "We've found that as visits per patient go up, income goes down," says Murray. That's because fixed costs remain the same, yet RVUs won't be as high if you bring a patient back excessively for treatment of their chronic disease, instead of packing the most into each visit. Seeing a patient for suture removal, after someone in the urgent care clinic stitched him up, is also a "low-RVU visit," he says. "To grow in a competitive market, you don't want to fill up the schedule with less-valuable RVUs."

The other benefit of this system, he says, is that by enabling practices to capture most of today's potential revenue today, it allows them to make an immediate assessment of their capacity to grow. Some physicians find they don't have enough appointments to fill up the day. Others find that, by realigning the roles of support staff, they can reduce the typical appointment block from, say, 20 minutes to 15, and add another appointment each hour.

"Once you uncover hidden capacity, you can expand the practice today," says Murray. "Your competitors can't. That's a huge advantage."

Practices with capitation contracts gain the ability to handle a bigger panel of patients and command more dollars from the plans they contract with. Because patients will be making fewer office visits, physicians can enlarge panel size without working longer hours.

The increased efficiency also means that these practices can grow without the expense of hiring additional physicians, he says. Some capitated practices have discovered that their patients no longer need to visit urgent care clinics. And not having to see patients who've already been treated in urgent care clinics or ERs, he adds, eliminates the cost of caring for the same patient twice.

Physician organizations, however, should not forget that the main goals of practice re-engineering are to increase patient, doctor, and staff satisfaction and improve clinical outcomes, says FP Gordon L. Moore, associate chief medical officer, managed care organizations, for Strong Health. If they can also reap financial benefits, he says, that's even better.

This is the third article in a monthly series on re-engineering office-based practices. Next up: how "care teams" of physicians and staff members can streamline and improve the care process. Later installments in the series will cover such topics as redesign of office space; phone systems; how to make the most of each visit; telephone treatment and other nonvisit care; measurement of how changes improve care, efficiency, and satisfaction; and the financial implications of re-engineering.

Ken Terry, ed. . You mean I can see the doctor today?.

Medical Economics

2000;6:102.