1. www.pspbc.ca Advanced Access/Office Efficiency for Specialists

2. 2  Decrease the wait of patients for an appointment with a specialist  Decrease the time patients spend at an appointment with a specialist  Increase the use of a care delivery mechanism that is efficient, effective, and improves capacity (Group Medical Visit)  Improve the provider and staff experience  Improve the patient experience and outcomes What are we trying to accomplish?

3. 3  Systems work more efficiently, more effectively, and at a lower cost when they work with no delay “Every system is perfectly designed to get the results it gets.”

4. 4 What’s the current state in your “system”?

5. 5 What if…. You could offer your patients an appointment with the specialist of their choice at a time that was convenient for them? What would it take? © Tantau & Associates

6. 6  Saturated schedules into the future  No flexibility  Triage & rework using expensive resources (MD and RN)  Multiple appointment types  Urgents and routines juggled  Capacity: overbook and over there  Continuity: delayed Traditional model 100% booked “Do last month’s work today.”

7. 7  Referred patients are offered an appointment with any provider within five days  Backlog eliminated (good vs. bad)  Continuity is improved/maintained  Capacity for new patients is increased  Optimal ratio of new:return is maintained  Increased patient, physician and staff satisfaction  Change how to do follow up Advanced Access Model 65% open 35% booked “Do today’s work today.”

8. 8  In Specialty, care is better, physicians, staff and patients are happier, costs are lower, and income is increased when the right people receive the right care and with minimal delay  Decreased no-shows (decreased waste)  Improved outcomes (more timely)  Increased patient and referring GP satisfaction  Increased provider and staff satisfaction  Decreased cost/visit Benefits of Improved Access

9. 9  Balance demand and supply daily › Shape the demand for new and return › Reduce or plan for supply variation  Reduce backlog  Reduce scheduling complexity  Optimize the care team Key Concepts for Access Improvement

10. 10  Choose appointment type  Select day & time (e.g. Mondays at 11:00)  Count days a patient waits  Repeat weekly and chart  Gold standard for 3 rd next for specialist: 5 days Measure of Access (delay): 3rd Next Available Appointment

11. 11  Office Based Medical Specialty: › To offer an appointment within 5 days of the date of referral.  Surgical Specialty: › To offer a surgical date within 5 days of agreeing that a surgical intervention is recommended. Ideal Access Aim ©Tantau & Associates

12. 12 Supply and demand Caseload: creates real work Waiting: creates re-work waiting reservoir Demand (referrals plus caseload) Supply (physician available to do the work )

13. 13  Number of appointment slots available to patients in a given day  Needs to balance the demand for appointments  Constant tension between new and return visits that must be taken into account Supply

14. 14  New: › Referral from GP office › Referral from ER › Telephone calls › Specialist to Specialist referral › Returns (Follow-up)  Physician-initiated (internally generated) › Requests patient come in for a follow-up visit (which is booked today) Demand (requests for services/time) …/

15. 15  Measure supply and demand  Match demand with supply › Build in adjustments for predictable blips (long weekends, etc.) › Reduce appointment types (increases flexibility, patient focused) › Consider group visits to increase supply Balancing Supply and Demand

16. 16  Choose a typical week in the future  Count every available appointment slot  Count pre-defined double-booking slots as two  Does not include time booked for admin, teaching, rounds, etc.  Result = available slots per week to meet patient demand Measuring Supply

17. 17  Record every request for an appointment whether or not an appointment is booked  Track “new” vs. “return” demand  Count appointment requests from all sources (all referrals for a consult)  Count the demand on the day request comes in Measuring Demand

18. 18  Paper records – count active charts  EMR  Billing software Determine Practice Caseload

19. 19  Delay in your system which represents scheduled, but currently unmet clinical service  Two types: › Good backlog = appropriate follow-up/planned future appointments › Bad backlog = today’s work pushed into the future e.g., patient needs to be seen today but cannot be accommodated  To calculate backlog: › Count total booked appointments until 3rd next; Subtract “good” backlog. Balance = true backlog Backlog

20. 20  Ideas: › Add ½ hour a day or a few hours a week › Increase hours on busiest days › Move some appointments from the future to any open slots in today or tomorrow’s schedule › Offload work (e.g., shared practices) › Increase supply – locum, RN, etc. Clearing Backlog Continue to try to do today’s work today …/

21. 21  Ideas › Review future schedule to determine appropriateness of appointments  Reduce frequency for follow-up visits? › Adjust schedule to match trends › Block some :10 minute ‘do not book’ slots › Reduce appointment types  short for regular visits/ long for physicals, etc. Clearing Backlog Continue to try to do today’s work today

22. 22 Clearing Backlog – Long Term Continue to try to do today’s work today Ideas  Make better utilization of MOA, RN, LPN and other team members’ skills to: –take BP, weight etc. –discuss medications with patient –review lab results –take patient histories Consider group visits

23. 23  How many types of appointments do you have?  Does your day follow your schedule of appointments as anticipated? Do you start and end appointments and your day on time?  Reduce the number of appointment types you use  Ensure truth in scheduling, i.e. schedule according to clinical need rather than template or habit  Use “Freeze-Unfreeze” for “time out of office” such as vacation Reducing Scheduling Complexity

24. 24  A “Practice Re-entry Survival Plan”  Before holidays, all appointment slots for the physician’s first week back are frozen  During the last week of the physician’s vacation, the MOA will gradually unfreeze part of the first week back from vacation Freeze / Unfreeze

25. 25  Appointments start and end on time  Work days start and end on time  The office visit is optimized; patient-provider time is protected  Rework and duplication of work is decreased, thereby increasing capacity › Rooms › Staff › Provider  Satisfaction of patient, staff and provider are increased  Costs/visit are decreased  Income is increased Benefits of Improved Office Efficiency

26. 26  Work is streamlined and standardized where possible  The care team’s roles are optimized  Needs are predicted and anticipated Key Concepts for Improving Efficiency Source: IHI.org

27. 27  This is a measure of the time an appointment takes for the patient  The measure includes time between “check-in” and “check-out”  Includes all segments of an appointment, including provider- patient interaction  In Specialty, this may include more than one provider in the course of a visit  Can be captured with the assistance of the patient Measure of Office Efficiency – Cycle Time

28. 28  1. Complete assessment of common practice processes Each staff member has opportunity to evaluate what works well and what doesn’t › Evaluate the current state of these processes  2. Complete a clinic walk-through  3. Map your processes Get to Know Your Work

29. 29  Each practice team member fills out the “Know your Processes: Specialty” form Know your processes – activity You have ___ minutes for this activity

30. 30  Each of the processes identified for improvement should be mapped in its current state  Once you have mapped the current state of a process, identify some possible small tests of change that could improve the process  Use the Plan, Do, Study, Act (PDSA) cycle to try small tests of change  Measure baseline and outcomes Steps for Improvement

31. 31  What is a “process”? › A series of connected steps or actions with an identifiable start and end point › Leads to a specific outcome  Why map a process? › It illustrates “how things work in our clinic or program” › Includes several perspectives › Starting point for improvement Process Mapping

32. 32  Oval - the start and end of the process  Box - the tasks or activities of the process  Diamond - a question is asked; a decision is required  Arrow - the direction or flow of the process Process Mapping

33. 33  Instructions  In your groups, create a process map to illustrate one of the processes identified in “Know Your Processes”  Start point: ……………  End point: …………… Process mapping – activity You have ___ minutes for this activity

34. 34  Where are the hand-offs?  Is it clear who does what?  Where are the delays?  Is there duplication or rework?  Are there identifiable areas where a small change could make an improvement? Analyze the process

35. 35  Have a staff member pose as a patient and walk-through a clinic process  Tell the staff about the walk-through and ask them to act normally  Start the process with the pre-process step and continue the process through to completion  Document the starting time of each step in the process, what works well, what does not work well, what thoughts you have for improvement, what feelings you experienced during the process Clinic Walk-through

36. 36 Cycle Time - Patient flow through the clinic Registration Patient enters clinic Clinic Room Provider-Patient Interaction Completion of procedures/orders Checkout Red Zone Pre-Red Zone Post-Red Zone Cycle time Non-appointment time =

37. 37 Improved Cycle Time - Patient flow through the clinic Registration Patient enters clinic Clinic Room Provider-Patient Interaction Completion of procedures/orders Checkout Red Zone Pre-Red Zone Post-Red Zone Non-appointment time = Cycle time

38. 38  Who does what?  Who could do what?  Who should do what? Optimize the Practice Care Team

39. 39  What it is  Brief morning meeting to › review schedule › deal with issues left over from previous day › anticipate needs for current day › give ‘heads up’ for anything special to be aware of › Brief – no more than 5-10 minutes  Why use it  Being proactive › helps ensure smoother patient flow › may help divert potential problems › improves communication between team members Structured Huddle

40. 40 http://adventuresinimprovingaccess.blogspot.com

41. 41  What are we trying to accomplish? (Aim)  How do we know a change is an improvement? (Measures)  What changes can we make that will result in an improvement?  Draft your small test of change with your practice team (e.g. each physician and MOA)  Share your plan with the group (report-out) Practice team activity – Planning for your small test of change You have … minutes for this activity

42. 42  Next visit to be held ________  Don’t forget to send in your information for CMEs and remuneration for your time  Good luck with your changes! Closing