1. Improving Access Harry Pigman, M.D. Associate Chief of Staff VA Medical Center, New Orleans

2. Aim 4 We will implement changes that will significantly shorten the delay patients experience in obtaining scheduled visits with subspecialists. 4 A model approach that can be applied to all clinics will be developed.

3. Understand the System New PatientAppointmentClinic ProcessFollow upDischarge

4. Understand Capacity in GU 4 Clinics per week 4 Available appointments per clinic 4 Types of GU clinics –General urology –Infertility clinic –Oncology 4 Staffing patterns

5. First Interventions 4 Extinguish demand for ineffective care - Greater than 6 months for return visits –Eliminate unnecessary visits –Identify outdated policies 4 Match capacity to demand - Abolish GU specialty clinics –Eliminate unproductive periods

6. Check First Interventions

7. Understand Demand

8. Key Point Concerning Demand Much of our work is generated by us and is unnecessary

9. Next Interventions 4 Extinguish ineffective care –Identify and implement best practices for return visit by diagnosis 4 Implement guidelines for care by diagnosis –Hematuria –Urinary tract infection –Sexual dysfunction

10. Holding the Gains

11. Spread Innovation - Eye Clinic

12. Highlights of Eye Interventions 4 Triage - Clinic chief review of consults before scheduling 4 Manage the constraint - Strict eligibility criteria for consults 4 Eliminate backlog - Review of existing appointments by chief

13. General Issues in Open Access 4 Eliminate backlog 4 Manage no shows 4 Minimize walk-ins

14. Eliminate backlog 4 Find unused capacity –Keep work at the lowest level 4 Eliminate unnecessary work 4 Bite the bullet

15. Manage No Shows 4 Structure work to accommodate missed appointments 4 Client centered scheduling –Give them a choice 4 Reminders for appointments 4 Shorten time to appointment 4 Place responsibility for appointment on client

16. Minimize walk-ins 4 Improve access –Multiple access points for forms, FAQs –Telephone access –Express lane model

17. Final Observation 4 Industry has gone through several stages in its history of quality improvement 4 Each stage of evolution has created an infrastructure for the next stage 4 Government is at the beginning of the quality journey 4 More you learn about quality improvement, the more successful you will be