1. Advanced Access Appointments Paul Cano MD, FCFP Smithville Family Health Team May 6, 2011

2. Smithville Family Health Team 8 family physicians (5.5 FTE) 8 family physicians (5.5 FTE) Serves a rural area of West Lincoln Township Serves a rural area of West Lincoln Township ~ 10000 patients ~ 10000 patients All MD’s serve at WLMH in Grimsby All MD’s serve at WLMH in Grimsby Teaching practice (McMaster) Teaching practice (McMaster)

3. Smithville Family Health Team Staff: 6 RN/RPN, 3 FTE 6 RN/RPN, 3 FTE 6 Secretaries, 4 FTE 6 Secretaries, 4 FTE 1 Office Manager 1 Office Manager 4 Scanning, 2 FTE 4 Scanning, 2 FTE IT support, 1 FTE IT support, 1 FTE Clean/stock ½ FTE Clean/stock ½ FTE FHT:2 RN’s, 2 NP’s, 2 MH, 1 Dietician, 1 admin, ½ secretary

4. The Problem… Waiting times for appointments for: - today’s appointments after they fill up (“Call tomorrow at 9AM…”) - urgent appts to see pts own FP (“I don’t have anything with Dr. Cano for 2 weeks, but I can offer you …’) - physicals (“Dr. Cano is booking 3 months from now”)

6. The Problem… Canada is the worst country in the Commonwealth for being able to get an appointment in the next 24 hours (39% vs. 50-75%)

7. The Problem compounds … Receptionists are forced to ‘triage’ the problem Receptionists are forced to ‘triage’ the problem They spend 5 times longer on the phone with the patient They spend 5 times longer on the phone with the patient ‘Queue jumping’ – pts learn what to do to get in quicker (crying, suicidal, short of breath) ‘Queue jumping’ – pts learn what to do to get in quicker (crying, suicidal, short of breath) Pts get care elsewhere in meantime, then 50% see you anyway (“I kept this appt because...”, then you get to review the other visits) Pts get care elsewhere in meantime, then 50% see you anyway (“I kept this appt because...”, then you get to review the other visits) Seeing pts that are not your own results in longer visits Seeing pts that are not your own results in longer visits No shows when the appt finally comes around No shows when the appt finally comes around

9. Complexity of Schedule We had several different appointment types — Physicals, WBV/PN, Urgent, ER We had several different appointment types — Physicals, WBV/PN, Urgent, ER We had multiple rules about these appointment types: We had multiple rules about these appointment types: E.g. 2 physicals / half day, except not 2 female physicals as they generally take longer, except if the female is younger E.g. 2 physicals / half day, except not 2 female physicals as they generally take longer, except if the female is younger The schedule worked well some days if … I or my secretary or my nurse looked ahead and rearranged a future day where the appts didn’t look like a good mix, calling patients to change their times The schedule worked well some days if … I or my secretary or my nurse looked ahead and rearranged a future day where the appts didn’t look like a good mix, calling patients to change their times

10. What Is Advanced Access? Also called ‘Open Access’ Also called ‘Open Access’ A method of adding capacity to a practice by not booking ahead A method of adding capacity to a practice by not booking ahead In it’s pure form, patients call and are seen the same day In it’s pure form, patients call and are seen the same day

11. Where Did it Come From? Pioneered by Dr. Mark Murray, a family physician with Kaiser Permanente in California Pioneered by Dr. Mark Murray, a family physician with Kaiser Permanente in California Taken from Best Practice in Industry Taken from Best Practice in Industry Used in HMO’s to increase # of patients that can be served without increasing staff Used in HMO’s to increase # of patients that can be served without increasing staff

12. The Philosophy… Do Today’s Work Today Do Today’s Work Today Although demand for services is variable, it is also predictable Although demand for services is variable, it is also predictable Don’t make things more complex than they need to be Don’t make things more complex than they need to be

13. Reduce Appointment Types With the goal to do today's work today, the distinction between urgent and routine is no longer necessary. The only distinctions between appointment types needed are: Provider is present vs. provider is absent Provider is present vs. provider is absent A short appointment type for return visits A short appointment type for return visits A long appointment type for physicals and new pts A long appointment type for physicals and new pts

14. Reduce Appointment Types When the provider is present the patient is seen When the provider is present the patient is seen When the provider is absent the patient is offered the choice of an appointment the next time the provider is present or today with another care team member When the provider is absent the patient is offered the choice of an appointment the next time the provider is present or today with another care team member All other special appointment types, such as for disease entity or physicals by age groups, can be eliminated. All other special appointment types, such as for disease entity or physicals by age groups, can be eliminated. Reducing appointment types simplifies telephone appointment triage, allows more flexibility for patients, and reduces queuing Reducing appointment types simplifies telephone appointment triage, allows more flexibility for patients, and reduces queuing

15. Commit to Doing Today’s Work Today In clinics with this system, the only appointments that are on the books at the beginning of each day are the return appointments that were generated by physician discretion or patient preference on a previous day In clinics with this system, the only appointments that are on the books at the beginning of each day are the return appointments that were generated by physician discretion or patient preference on a previous day There are no "frozen" or held appointment slots, as this provides maximum flexibility in the system to absorb daily demand. There are no "frozen" or held appointment slots, as this provides maximum flexibility in the system to absorb daily demand. It has 2 requirements: It has 2 requirements: -supply and demand are in balance, and supply and demand are in balancesupply and demand are in balance -that the backlog is eliminated backlog is eliminatedbacklog is eliminated

16. Who has done it? USA HMO’s such as KP USA HMO’s such as KP UK practices in a quality initiative UK practices in a quality initiative Taber Alberta, Cape Breton Taber Alberta, Cape Breton Ontario practices: Cambridge Grandview, Chatham Tilbury, Burlington Caroline, Toronto New Heights CHC, Wawa Ontario practices: Cambridge Grandview, Chatham Tilbury, Burlington Caroline, Toronto New Heights CHC, Wawa

17. Results Taber (Alberta) – decreased asthma visits to ER by 33% Taber (Alberta) – decreased asthma visits to ER by 33% New Heights (Toronto) – average wait from 30 days to <8hrs for same day New Heights (Toronto) – average wait from 30 days to <8hrs for same day

18. Results No shows – New Heights reduced rate from 23.5% to 15% No shows – New Heights reduced rate from 23.5% to 15% - Nottingham reduces from 160/month to 20/month Capacity – New Heights increased the number of pt encounters by 41% over 14 months Capacity – New Heights increased the number of pt encounters by 41% over 14 months

19. Advanced Access “Heard it through the grapevine” “Heard it through the grapevine” Learned the specifics through a Quality initiative our practice joined (‘QIIP’) Learned the specifics through a Quality initiative our practice joined (‘QIIP’)

20. My “3rd next appt” – Summer 2009

21. How to Implement Get buy in from your staff Get buy in from your staff Measure your supply and your demand Measure your supply and your demand Analyze patterns of usage Analyze patterns of usage Plan your schedules and processes based on your own data Plan your schedules and processes based on your own data Set a start date Set a start date Work down the backlog Work down the backlog

22. How we Started Got staff to ‘buy in’ Got staff to ‘buy in’ Measured supply and demand, determined that my current schedule can meet demand Measured supply and demand, determined that my current schedule can meet demand Started in summer 2009, and set a date 3 months in advance (Oct 1 st ) as a start date (this was where my ‘physicals’ were booked up until) Started in summer 2009, and set a date 3 months in advance (Oct 1 st ) as a start date (this was where my ‘physicals’ were booked up until)

25. Measuring Supply and Demand Supply: When you are available for patient appointments Supply: When you are available for patient appointments Daily Demand: appointment requests each day Daily Demand: appointment requests each day Demand is both ‘external’ (patient initiated), and ‘internal’ (provider initiated) Demand is both ‘external’ (patient initiated), and ‘internal’ (provider initiated) Got staff to measure Got staff to measure

27. Data Collection Challenges Multiple secretaries Multiple secretaries Differing commitment to the goals Differing commitment to the goals Better buy in after I had implemented it successfully Better buy in after I had implemented it successfully ?easier to collect for all docs, not just 1 ?easier to collect for all docs, not just 1

28. Demand Measures My practice is 1450, about 85% rostered My practice is 1450, about 85% rostered Actual total demand – weekday average is: Actual total demand – weekday average is: 12.6 measured pre AA (15.4 measured post AA – more accurate) Internal / External demand proportion Internal / External demand proportion 34 + 66% before Advanced Access 20 + 80% after AA

29. Demand Estimates – ICES Based on measured annual visit rates of age groups in Ontario (0-1, 1-4, 5-9, etc.) Based on measured annual visit rates of age groups in Ontario (0-1, 1-4, 5-9, etc.) Sept 2007 – Aug 2008 Sept 2007 – Aug 2008 Includes patient visits to all primary care physicians, not just their own family doc Includes patient visits to all primary care physicians, not just their own family doc Includes walk-in clinics Includes walk-in clinics Excludes ER visits Excludes ER visits Does not include non-rostered patients Does not include non-rostered patients Separate estimates for FHT, FHO, FHN, FHG,FFS Separate estimates for FHT, FHO, FHN, FHG,FFS

30. Demand Estimates – ICES Used my total practice number (not just rostered patients) Used my total practice number (not just rostered patients) Plugged numbers in to the spreadsheet Plugged numbers in to the spreadsheet 3,791 visits/year / 46*5 3,791 visits/year / 46*5 = an average of 16.48 visits/weekday An overestimate as based on total visits to ALL GP’s (so perhaps useful…) An overestimate as based on total visits to ALL GP’s (so perhaps useful…)

31. Matching My Supply to Demand My weekly schedule: Monday AM Monday AM Tuesday Eve Tuesday Eve Thursday AM Thursday AM Thursday PM Thursday PM Friday AM or PM Friday AM or PM My weekly demand Monday – 19 (23) Monday – 19 (23) Tuesday – 12 (16) Tuesday – 12 (16) Wednesday – 10 (8) Wednesday – 10 (8) Thursday – 13 (18) Thursday – 13 (18) Friday – 10 (12) Friday – 10 (12) Average – 12.6 (15.4) Average – 12.6 (15.4)

32. Matching My Supply to Demand My weekly schedule: Monday AM (16) Monday AM (16) Tuesday Eve (16) Tuesday Eve (16) Thursday AM (16) Thursday AM (16) Thursday PM (12) Thursday PM (12) Friday AM or PM (16) Friday AM or PM (16) My weekly demand Monday – 19 (23) Monday – 19 (23) Tuesday – 12 (16) Tuesday – 12 (16) Wednesday – 10 (8) Wednesday – 10 (8) Thursday – 13 (18) Thursday – 13 (18) Friday – 10 (12) Friday – 10 (12) Average – 13 (15) Average – 13 (15)

33. Matching Supply to Demand Supply was about right for 16 visits / day Supply was about right for 16 visits / day Bookings changed from 10 minute intervals with lots of precoding, to 15 minutes intervals with little precoding Bookings changed from 10 minute intervals with lots of precoding, to 15 minutes intervals with little precoding

35. Contingency Plan for Vacations Plan in advance Plan in advance Measure the length of vacation Measure the length of vacation Don’t prebook anything (if possible) for an equal length of time after the vacation ends (call it the ‘vacation recovery period’) Don’t prebook anything (if possible) for an equal length of time after the vacation ends (call it the ‘vacation recovery period’) The vacation recovery period opens up to appointments once the vacation starts The vacation recovery period opens up to appointments once the vacation starts

36. Staff Training Initial meeting to outline concept, set start date, and establish ‘rules’ (as little rules as possible!) Initial meeting to outline concept, set start date, and establish ‘rules’ (as little rules as possible!) Explained my new schedule: now 4 slots / hour, from a previous 5-6 / hour (15 minutes slots vs. 10 minute slots) Explained my new schedule: now 4 slots / hour, from a previous 5-6 / hour (15 minutes slots vs. 10 minute slots) Initial Rules: limits on number of appts to be prebooked each day Initial Rules: limits on number of appts to be prebooked each day - what can and couldn’t be prebooked (later relaxed this, let them prebook if they wanted to) - 2 slots for CPX, everything else 1 slot

37. Sent a Letter to Patients A lot of work (review of roster) A lot of work (review of roster) It did save my time in explaining to patients at end of visits when questions about when / if to rebook It did save my time in explaining to patients at end of visits when questions about when / if to rebook

38. Letter To My Patients … I would like to let you know about an exciting change in my medical practice that will be taking place over the upcoming months! Please feel free to share the information with any of your family members or friends who may also be patients of mine. ‘Advanced Access’ for Appointment Bookings Starting on October 1st, I will be keeping about 2/3rd’s of my appointments each day open for booking either that day, or the day before. As a result, the number of ‘pre-booked’ appointments (appointments that can be booked well in advance) will be limited to about 1/3rd of that day’s appointment slots. The idea behind this new booking method (known as ‘Advanced Access’) is to make myself more available to you on the day that you call in for an appointment.

39. Working down my backlog I added 2-3 extra half days over the 3 months I added 2-3 extra half days over the 3 months There should be no ‘unmet demand’ when advanced access starts There should be no ‘unmet demand’ when advanced access starts

40. Working down my backlog "Max-Packing" "Max-packing" is doing as much for patients while they are in the office for any given visit, in order to reduce future work "Max-packing" is doing as much for patients while they are in the office for any given visit, in order to reduce future work I always did this somewhat, as I was lousy at being assertive with patients (“I can’t deal with that problem today …”) I always did this somewhat, as I was lousy at being assertive with patients (“I can’t deal with that problem today …”) RN looked ahead in the schedule, if multiple appointments we tried to do everything today RN looked ahead in the schedule, if multiple appointments we tried to do everything today long days! long days!

41. Working down my backlog Utilize team ‘huddles’ at the start of each day to plan for the day ahead. Utilize team ‘huddles’ at the start of each day to plan for the day ahead.

42. Other Implementation Details Some appts can/should still be prebooked (WBV, PN, dementia, mental health, chronic pain) Some appts can/should still be prebooked (WBV, PN, dementia, mental health, chronic pain) We eventually allowed any prebooking with just encouragement to book at last minute We eventually allowed any prebooking with just encouragement to book at last minute Still need to leave ½ day open for practice ER Still need to leave ½ day open for practice ER Frequent Flyers Frequent Flyers

43. Now, here is a typical week’s schedule before the week begins … Now, here is a typical week’s schedule before the week begins …

44. Monday October 19th

45. Tuesday October 20th

46. Thursday October 22nd

47. FridayOctober23rd

48. And, here is a schedule in ‘real time’ …

49. Tuesday October 13 th 9 AM

50. Tuesday October 13 th 10 AM

51. Tuesday October 13 th End of clinic

52. Contingencies ….

53. Sun 1/4 MonTuesWedThursFriSat1/4 7-9 Hosp rnds Hospital rounds / out patient Hospital rounds 9-1Clinic RN Home House Calls OffClinicClinicClinic 1-5 Admin, IT, forms, phone calls ResidentClinicClinic IT, forms, phone calls 5-9Clinic Emerg Shift

54. “Conference” Vancouver, Feb 2010

55. Conference Delegates Conference Delegates

56. Back in Smithville …

57. Networking …

58. Back in Smithville …

59. Trauma Demonstrations

60. Back at WLMH …

61. Small Group Workshops

62. Back in Smithville …

63. Dermatology …

64. Back at WLMH …

65. Groundbreaking Study Announcement

66. Face the Music I return from holiday …

70. Anecdotal Feedback Patients – is this going to last ? Patients – is this going to last ? Front Desk – love it! Front Desk – love it! I feel I am meeting my patients needs better I feel I am meeting my patients needs better No shows much less (was 28 / month, now 6 per month) No shows much less (was 28 / month, now 6 per month) I am too available to other’s patients! I am too available to other’s patients!

71. PC – Average waiting times (“3 rd next appointment)

72. No Shows / month

73. Income No change No change ?impact on pure FFS models? ?impact on pure FFS models?

74. PC = # of my pts appts in the office that are with me PC = # of my pts appts in the office that are with me

75. Where did we go from there? Presented this information to physician retreat in the first month Presented this information to physician retreat in the first month Are any interested in a ‘second wave’ of changing to Advanced Access? Are any interested in a ‘second wave’ of changing to Advanced Access? 3 said yes 3 said yes 2 said maybe 2 said maybe 2 said no 2 said no As of May 2011, 7 of 8 MD’s on AA As of May 2011, 7 of 8 MD’s on AA

76. JB (1400) – 3 days/wk, OB, ER (“3 rd next appointment)

77. KB (1105) – 3 days/wk (“3 rd next appointment)

78. MD (1070)– 3 days/wk (“3 rd next appointment) Returned Oct 09 ‘early’ from surgical leave, locum overlapped by 1 month as she worked part time

79. MNW (1360)– 4 days/wk, ER (“3 rd next appointment)

80. SS (930)– 3 days/wk, ER (“3 rd next appointment) Mat Leave locum from July 10 to Mar 11 Returned April 11 (pts were told May 11)

81. TS (1440)– 3 days/wk, GPA, OB (“3 rd next appointment)

82. AM (1140) – 3 days/wk, OB (“3 rd next appointment) Just went on Mat leave, will hopefully return to AA with help of locum

83. Summary Advanced access works! Advanced access works! - reduces 3 rd next appointment - reduces no-shows - reduces demand Get buy in Get buy in Measuring demand labourious but helpful Measuring demand labourious but helpful Estimating demand by ICES may be a short cut Estimating demand by ICES may be a short cut Varying expectations of what ‘open’ is to suite your practice Varying expectations of what ‘open’ is to suite your practice

84. References and Resources Murray M, Tantau C. “Same-Day Appointments: Exploding the Access Paradigm”. Family Practice Management. 2000, September. Murray M, Tantau C. “Same-Day Appointments: Exploding the Access Paradigm”. Family Practice Management. 2000, September. http://www.chsrf.ca/other_documents/pdf/Promising%2 0Practices_%20Advance%20Access%20ENG_FINAL.pdf http://www.chsrf.ca/other_documents/pdf/Promising%2 0Practices_%20Advance%20Access%20ENG_FINAL.pdf http://www.chsrf.ca/other_documents/pdf/Promising%2 0Practices_%20Advance%20Access%20ENG_FINAL.pdf http://www.chsrf.ca/other_documents/pdf/Promising%2 0Practices_%20Advance%20Access%20ENG_FINAL.pdf www.clinicalmicrosystem.org/access.htm www.clinicalmicrosystem.org/access.htmwww.clinicalmicrosystem.org/access.htm McCollum, WRK. “Improving Access in primary Care - The Advanced Access methodology”. www.salt.n- i.nhs.uk Oct 10, 2009, McCollum, WRK. “Improving Access in primary Care - The Advanced Access methodology”. www.salt.n- i.nhs.uk Oct 10, 2009,www.salt.n- i.nhs.ukwww.salt.n- i.nhs.uk www.ihi.org www.ihi.org www.qualityhealthcare.org www.qualityhealthcare.org

85. Thanks!! canop@mcmaster.ca canop@mcmaster.ca