American College of Physicians: Internal Medicine — Doctors for Adults ®

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Patients tired of waiting? Try these strategies

Faster scheduling and more same-day appointments are making for happier patients—and busier practices

From the October 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

When Ron E. Cirullo, ACP-ASIM Member, heard that patients from one of his clinics were going to local emergency rooms for follow-up care, he knew he had a problem. Those patients were being treated for conditions like chest pains and pneumonia—problems that should have been treated in his office.

Dr. Cirullo, medical director of PeaceHealth Medical Group in Eugene, Ore., soon found the cause of the trouble: The group's downtown office was so busy that patients simply couldn't get a timely appointment. As a result, some decided to take their problems to the local emergency room.

A closer look at the group's practices uncovered more problems. At another one of the group's sites, the 11-physician South Clinic, nearly a third of patients who called the practice to make an appointment hung up in frustration before they ever spoke to someone. Those who were able to talk to a scheduler often had to wait a month or two for an appointment with one of the internists or family practitioners. And once they were in the office, patients waited an average of 15 minutes in the lobby and another 32 minutes in the exam room.


'There is a myth that demand is insatiable. Demand is finite.'

—Mark Murray, MD


So in the fall of 1998, the group began to make some changes, beginning with the South Clinic. It created new clinical teams to change how physicians saw patients, put new staff in charge of scheduling appointments and created a new scheduling system that had physicians starting most days with more than two thirds of their appointment slots unfilled.

The results have been dramatic. Today, only 5% of patients calling the practice hang up before they reach a scheduler. Patients can see a physician the same day they call. And once patients arrive at the office, they wait an average of two minutes before entering an exam room and another eight minutes to actually see a physician. Other PeaceHealth locations have made similar changes.

PeaceHealth is one of 24 organizations that are taking part in a project created by the Boston-based Institute for Healthcare Improvement (IHI). The project known as the Idealized Design of Clinical Office Practices, seeks to improve overall access to medical services and reduce delays in appointment scheduling at both primary care and specialty practices.

Same-day service

IHI's key strategy is to provide same-day service. One of the more radical steps IHI is using to address scheduling problems is known as "open access," a system in which physicians begin the day with more than half of their slots available. Callers can get a same-day appointment regardless of the appointment type; even new patient visits and physicals are seen on the same day. Schedulers use a standard slot size—15 minutes, for example—and simply combine slots to make time for longer visits. As a result, waits (IHI calls them "queues") for specific types of appointments disappear.

IHI has found that, too often, physicians try to limit the number of longer appointments that they schedule. Many physicians, it seems, fear that if they perform too many physicals in one day, they will have to turn other patients away.

Charles M. Kilo, ACP-ASIM Member, an internist and director of the IHI program, acknowledged that for many physicians, the notion of open access is difficult to swallow. Some worry they'll be deluged; others, particularly in fee-for-service, are terrified of starting the day with a schedule as much as two-thirds empty.

Dr. Kilo, however, explained that the key to the system is realizing that you can predict demand for your services based on the number of patients in your practice. In general, internists can expect 0.7% of their patients to call during a given day. An internist with 2,000 patients, then, can expect to receive about 14 patient calls a day. (Dr. Kilo noted that the exact number will vary depending on how healthy or sick your patients are.)

As for the dreaded deluge of physicals, Dr. Kilo said that it doesn't usually materialize. Some days, physicians might do more physicals than they would have under traditional scheduling systems. Dr. Joseph Gomez, ACP­ASIM Member, for example, said he typically does two or three physicals a day in his Fairport, N.Y., practice under IHI's open access system, the same number he would have done otherwise.

Converting to an open access system requires some planning. Physicians must first eliminate backlogs to free up their schedules so they can take same-day appointments. As a result, they must often work additional hours in the evenings and on weekends to get the system up and running.

But once open access is in place, Dr. Kilo said, the schedule settles down. Dr. Gomez says he and his partner rarely work late.

Mark Murray, MD, a Kaiser-Permanente family physician who works with IHI and is a part-time consultant, studied the open access system at a Kaiser practice in Roseville, Calif., for 33 weeks in 1998. He found that during 11 of those weeks, the eight-physician practice—a mix of internists and family practitioners—saw more patients than they would have booked under their old system. During the other 22 weeks, however, physicians saw slightly fewer patients.

"There is a myth that demand is insatiable," said Dr. Murray. "Demand is finite."

The open access system can also improve other aspects of patient scheduling. While nearly a third of callers to PeaceHealth's South Clinic used to hang up while on hold, the open access system eliminated the need for schedulers to spend time on each call searching for an appropriate slot on an appropriate day. As a result, the "abandoned call" rate plummeted.

And at Medical Care Center North in Chelsea, Mass., a practice that is part of Affiliated Physicians Group, implementing the open access system has meant reduced patient waiting times in the office. The four-internist office cut the overall time patients spend in the office, including time spent with the physician, from 70 minutes in February 1999 to 37 minutes in May of the same year.

Because the practice's days aren't fully booked, last-minute patients with acute conditions aren't being stuffed into already full schedules. "In many standard offices, you would be double- or triple-booking those patients," said Philip Triffletti, ACP-ASIM Member, an internist in the office and associate medical director of Affiliated Physicians Group.

Here are other strategies that practices working with the IHI project are using to improve appointment scheduling systems—and reduce patient frustration:

Jam-packed visits. Open access is part of a broader efficiency ethic that encourages physicians to do today's work today instead of postponing problems and concerns for future visits. Because physicians pack as much business into each visit as possible, they are able to free up their schedules.

Dr. Triffletti said that if a patient who comes in for a sore throat also has a chronic disease such as diabetes, for example, he tries to use that time for the diabetes follow-up that might otherwise have occurred a month later. By freeing up his future schedule, he helps avoid overscheduled days.

Penn State Geisinger Health System's practice in Lake Scranton, Pa., which is also working with IHI, asks patients to fill out a short survey when they arrive at the office. The survey asks patients why they're seeing a physician, whether they are expecting the results of any tests, whether they've changed medications and whether they have any other questions they would like to discuss with the physician. The completed survey goes to a nurse, who then performs any necessary tests before the physician sees the patient.

The survey also helps physicians pick up on issues that patients are reluctant to discuss, said Michael J. Fox, MD, an internist with the practice. Consider a patient treated for elbow pain. Often, Dr. Fox said, "They'll leave and invariably I'll get a call: 'Can I go back to playing tennis?' Thanks to the survey, he said, you've taken care of that question."

Intuitively, internists worry that reducing visits will hurt patient care. IHI proponents, however, argue that the opposite is true. Dr. Triffletti noted that easier access and shorter waits make it less likely that a patient's condition will get worse while waiting for an appointment.

Standardization. Another IHI strategy is to have practices standardize the organization of their exam rooms.

Dr. Fox said that because supplies at his practice were haphazardly placed in exam rooms, physicians or nurses would waste time searching for alcohol or Pap smear supplies. To solve this problem, physicians, nurses and staff met to decide exactly what equipment and supplies each exam room should contain and where each item should be located. Now a supply checklist is inside each supply cabinets, and nurses keep them stocked.

Dr. Fox said that while standardizing the exam rooms cost next to nothing, it has shaved minutes off of visits that used to be spent searching for lydocaine or swabs.

Practices working with IHI are also taking a look at how they handle requests for prescription refills. The Fargo, N.D., practice of James A. Volk, ACP-ASIM Member, for example, asks pharmacies to use a fax form it created to ask questions about prescriptions. The number of phone calls from pharmacies, which once accounted for the practice's third highest volume of calls, dropped by more than 80%, reducing wait time for patients on hold.

Team-building. At PeaceHealth in Eugene, physicians used to be paired with a nurse or medical office assistant. If a physician needed help with a patient—a male physician wanting a nurse in the room during a breast exam, for example—the physician had to hunt for someone and wait if she was on the phone, with a patient or in the lab.

The practice has created teams to address such issues. Each team now typically includes four physicians; a resource nurse (an RN) to do patient education and triage; three "roomers" (an RN, LPN or medical assistant) to take the patient to the exam room, take vitals and make sure medications are up-to-date; and one person (RN, LPN or medical assistant) scheduling visits and doing such clerical work as laboratory call-backs and making appointments for MRIs. When a physician needs help, chances are good that one of the team members will be available.

The teams in Dr. Fox's office include a physician, nurse, medical records person and appointment secretary. They meet daily for a 15-minute morning "huddle" to plan the day. The team flags patients who will need tests done, so the staff can get those started when the patient checks in. As a result, patients spend time in the lab instead of in the waiting room, and test results are available before the physician enters the exam room.

Financial impact. Some internists fear these strategies will hurt revenue. Though the IHI project is too new to prove it with numbers, Dr. Kilo said that he expects the opposite to be true. The key to improved financial performance, he said, is increasing your panel size.

According to Dr. Kilo, a practice that reduces unnecessary appointments and improves efficiency, increases its capacity to see new patients and therefore boosts overall panel size. In capitated practices, this means more patient-per-month income. In a fee-for-service setting, this means that internists can spend their time seeing cases with higher reimbursement rather than the same people over and over for low-paying minor problems.

"Folks in the fee-for-service world think that finances are based on office visits," Dr. Kilo said. "It's panel size that matters. There's a lot of room for growth. That's a real mindset shift in the fee-for-service world."

Bryan Walpert is a freelance writer in Denver.

For more information about IHI's Idealized Design of Clinical Office Practices, contact Charles M. Kilo, ACP-ASIM Member, at ckilo@ihi.org or visit IHI's Web site at www.ihi.org.


A novel approach for capitation: group visits

In an effort to improve patient scheduling, some heavily capitated practices are trying an unusual approach: seeing patients in groups.

Using the drop-in group medical appointment (DIGMA) model, physicians hold regular meetings for groups of patients suffering from the same disease or condition. Internists might see cardio/pulmonary patients the first week of each month, diabetes patients during the second week, patients with chronic pain during the third week and patients suffering abdominal stress in the fourth week. (Patients not interested in the groups are free to make individual appointments.)

The meetings, which can last up to an hour and a half, allow patients to interact with one another and provide many of the same services offered during routine visits. Groups typically range in size from 12 to 22 and sometimes include spouses and family members. Physicians work with a behavioral health professional such as a psychologist to address emotional issues that come up during the meeting.

Lynn A. Dowdell, ACP-ASIM Member, an endocrinologist at Kaiser Permanente who provides primary care for many of her patients, held her first group meeting for diabetic patients in early 1998. Before each meeting starts, a medical assistant checks blood pressures, weights and pulses. Dr. Dowdell then reviews blood sugars, writes prescriptions, discusses medications and side effects, checks thyroids and orders X-rays and mammograms.

Dr. Dowdell typically talks to each patient in a semi-public manner. The whole group listens, since the conversation may be relevant to other patients in the group. (A nearby exam room is available for patients who want more privacy.)

Before she began using the DIGMA model, Dr. Dowdell's patients waited months to see her. By inviting diabetic patients to come to the group meetings, she has reduced the number of patient telephone calls that need to returned, freeing up more time to see other patients.

So far, the DIGMA model has been used in capitated HMOs like Kaiser, which stand to gain from fewer patient visits. Edward B. Noffsinger, PhD, a health psychologist who designed the DIGMA model for a Kaiser practice in San Jose, Calif., said it isn't clear how physicians seeing fee-for-service patients would be reimbursed using the model.

But for Dr. Dowdell, the real benefit has been for patients, who learn more from talking to each other at group meetings than she could have ever imagined. One of her diabetic patients resisted using insulin until hearing about another patient's experiences. When another asked where to buy shoes, a group member suggested a custom shoe shop in the area.

"It was wonderful," Dr. Dowdell said, "because I couldn't have answered that question at all."

For information about the DIGMA model, contact Edward Noffsinger, PhD, at 408-395-8616 or 831-458-3388.

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