1. Mark Murray & Associates 916-441-3070 murraytant@msn.com ACCESS IMPROVEMENT How to see Differently Mark Murray, MD, MPA

2. AccessAccess An access problem is a delay problem An access problem is a system problem

3. Every system is perfectly designed to get the results it gets. Results

4. TermsTerms n Demand: what the customer wants/what we should be doing n Activity: what we are doing n Supply: what we could be doing n Backlog: what we should be doing but haven’t n Wait list/queue/work in progress/inventory/warehouse=backlog n Constraint/bottleneck: the rate limiting step

5. Why focus on delay? n Delays lead to patient dissatisfaction n Delays lead to staff dissatisfaction n Delays lead to provider dissatisfaction n Delays cost money n Delays sub-optimize revenue n Delays adversely effect clinical outcomes n We can only go as fast as the slowest step n Perception that delay=lack of resource

6. Why do queues form? n Demand > Supply n Variation n Paradigm n Buffer for revenue, for predictability and for assurance of 100% utlilization ( false productivity)

7. Demand > capacity Demand > capacity Time waiting numbers If Demand > Activity or Capacity

8. Sources of demand variation n Randomness of presenting patients n Randomness of clinical condition/acuity/time n Randomness of internally generated demand n System factors ( includes discontinuity, future open schedule etc)

9. Sources of supply variation n Lack of time in/out policies n Number of providers n Pattern of providers n Carve outs that restrict flexibility n Other system constraints ( rooms, staff, equipment etc)

10. Moment of truth n Even if the average demand = average supply n The variation of demand + the variation of supply n Will result in a queue

11. Demand & capacity for breast clinic 0 20 40 60 Week Number 3 January 2000 22nd January 2001 Total number of patients referred Number of clinic slots available

12. Computer model demonstration

13. ConstraintsConstraints Demand in the population Request for service constraint Access to that service Delivery of that service Access to secondary service constraint

14. Access Improvement n Team n Aim n Changes n Measures

15. Model for Reconstruction n D:S n D = S n D reduction n S enhancement

16. Demand Supply 2 MONTHS FTKA Triage Rework

17. Critical Access Design Elements n Continuity n Appointment capacity

18. ModelsModels n Traditional Model n Carve Out Model n Advanced Access Model

19. R H R OPEN R H R H R H R H R H R H R H R H R H R H R H R H R H H R H R H R H H MTWTHF Carve Out One Month View R=Routine H=Held Demand ©Murray / Tantau

20. Return OPEN Demand MTWTHF Patient Choice OPEN Return OPEN Patient Choice OPEN Return OPEN Patient Choice OPEN Return OPEN Patient Choice OPEN Return OPEN Patient Choice OPEN Advanced Access - One Week View No specific time for this “good backlog”

21. Advanced Access n Fears: –Saturated schedules –Demand is insatiable –Panel size n Pitfalls: –Panel size –Supply side variation n Do all today’s work today

22. Old Old In order to protect today, we push work to tomorrow. New New In order to protect tomorrow, we pull work into today.

23. ResultsResults n Patient satisfaction improved n Staff satisfaction improved n Provider satisfaction improved n Delays reduced n Continuity improved n Quality improved n Unnecessary visits reduced n Financial improvement

25. Physical Exams

26. Number of Days for 3rd Available Routine Appointment

27. 1 2 3 4 5 6 7 Alaska Native American Health Care Pediatrics

28. Match with PCP 2 Year Comparison Avg. 59% Avg. 72% % of Match

29. Improved Clinical Outcomes Interventions:  Health prompt  Continuity  Advanced Access 1998 Q4 1999 Q4 2000 1Q

30. Change in Visit Utilization April 1995 - March 1997 Sacramento

31. “Over and Under” Appointments

32. Improved Finances Average per month over 1 year

34. High Leverage Changes for Access Improvement n Balance demand and supply daily n Reduce backlog n Decrease appointment types n Develop contingency plans n Reduce demand for visits n Increase the supply

35. High Leverage Changes for OE n Balance the demand and capacity for non appointment work n Synchronize patients, providers and information n Predict and anticipate needs n Optimize rooms, equipment and staff n Manage the constraints