Advanced Access: How To Make it Work; Part A Catherine Tantau, BSN, MPA Tantau & Associates P.O. Box 179 Chicago Park, California 530-273-6550 [email protected].

Advanced Access:How To Make it Work;Part A

Catherine Tantau, BSN, MPA

Tantau & AssociatesP.O. Box 179

Chicago Park, California530-273-6550

[email protected]

© Tantau & Associates1

copyright Tantau & Associates

mailto:[email protected]

Objectives… Learn how to balance Demand and Supply

using practical, tested approaches Leave with an understanding of the basic

elements of an effective Backlog Reduction plan to close the gap between current delays and your access goals.

Recognize the value of, and strategies for, simplifying appointment types and times.

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First things first… Measure Delay for routine

appointments and elective procedures

Set an Access aim Why the Gold Standard? The strength of organizational aim

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High Leverage Changes forAccess Improvement

1. Match Demand and Supply Daily

2. Reduce Backlog

3. Decrease Appointment Types and Times

4. Develop Contingency Plans

5. Reduce Demand for Visits

6. Optimize the Care Team

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Sequencing for Advanced AccessMany options; one example of a tested path

Set Access Aim Measure delay for routine appt for each provider Measure Demand and Supply

These are not necessarily linear, consider parallel processing…

Empanel patients with a PCP and promote Continuity Match Demand and Supply, daily Work down the Backlog !!!!! Simplify appt types and time Develop Contingency Plans Reduce demand for unnecessary visits Optimize the Care Team

At every step… Track and display data at least monthly Celebrate successes and failures!

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1.Match Demand and Supply Daily…a review

Make a decision…

Carve-out or Advanced?

Improve Continuity using panel

information


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Demand

Illness Burden of Population

Mood and Attitude

Continuity

Practice Style

Measure: True demand

Demand Drivers: Panel Size, Case load,

return visit intervals…

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Measuring Appt Demand

Look at historical data?...no Worse case Scenario… Reassurance “real time” data Moment of Truth: Booking

transactions

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Demand

True Demand Formula:

External Appointment requests, called in and appted regardless of day

appted to (today or future)

+ Walk-ins for appts.

+ Other portals of entry if result in appt booked + Deflections we can count? (UCC ?)Internal

+ Returns booked today as pt leaves

Total Demand

Appointment Demand Worksheet

Date: ____________

Care Unit 3

Patients calling today, requesting appt, regardless of day appted to

(External)

Walk-Ins today

appted

(External)

Deflections,

eg UCC, if trackable

(External)

Return appts booked today as pts leave today’s appt.

(Internal)

Total Demand

Optional; Pts

turned away, not booked. Do not

add into Demand

Provider

A

Provider

B

Provider

C

Provider

D

Total

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Measured demand

Calls for visits

Other external demand

Internal demand

# appt per day

Monday 44 2 29 75Tuesday 34 5 25 64Wednesday 29 8 35 72Thursday 30 3 18 51Friday 37 1 31 69

Provider capacity

# appt per day

MondayTuesdayWednesdayThursdayFriday

VISIT RATEVisits per hour

Provider A 3Provider B 3Provider C 2.25Provider D 3Provider E 3Provider F 3

HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AMProvider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875

0

10

20

30

40

50

60

70

80

MondayTuesdayWednesdayThursday Friday

Appointment Demand

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Supply Macro Supply…dept level Deployment of Supply…bookable hours Measures

Measure when schedule is released. Appts per session for each day of week per provider. Estimate % long and shorts based on prior schedules

Hours per session ? Productivity standard? Office FTE modification

Process of Supply… What is the work? Who does the work? What can we try doing differently?

Appointment Supply Worksheet

Week of:____________

Provider

A

Mon

Tues

Wed

Thurs

Fri

Sat

Total

Supply

Provider B

Provider

C

Provider

D

Total

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Measured demand

Calls for visits

Other external demand

Internal demand

# appt per day

Monday 44 2 29 75Tuesday 34 5 25 64Wednesday 29 8 35 72Thursday 30 3 18 51Friday 37 1 31 69

Provider capacity

# appt per day

Monday 70.125Tuesday 61.5Wednesday 87Thursday 58.875Friday 84

VISIT RATEVisits per hour

Provider A 3Provider B 3Provider C 2.25Provider D 3Provider E 3Provider F 3

HOURS per session Mon AM Mon PM Total Tues AM Tues PM Total Wed AM Wed PM Total Thu AM Thu PM Total Fri AMProvider A 3.5 4 22.5 4 12 3.5 2 16.5 4 12 3.5Provider B 0 2.5 3 16.5 2.5 3 16.5 0 2.5Provider C 2.5 4 14.625 0 4 9 3.5 4 16.875

Appointment Capacity versus Demand

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Monday Tuesday Wednesday Thursday Friday

Provider capacity Measured demand

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Activity; the 3rd Dimension Activity is the measure of patients

who were actually seen today. At the end of the day, regardless of

demand or supply, count the number of patients seen.

Accounts for No Shows.

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One SF Clinic’s Progress Balancing Demand, Supply, Activity


Appointment Activity Worksheet

Week of:____________

Provider

A

Mon

Tues

Wed

Thurs

Fri

Sat

Total

Activity

Provider B

Provider

C

Provider

D

Total

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Three Dimensions;Demand, Supply, Activity

Average Supply & Demand December 12 - July 7

3 Appointments Per Hour

7975

60

73

82

63 62

5551 49

2732

24

33 35

0

10

20

30

40

50

60

70

80

90

Monday Tuesday Wednesday Thursday Friday

Supply Demand Patients Seen

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How to Track…How long to track…

Tic Marks vs Electronic tracking

4-6 weeks and then forever

Separating Internal from External

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Apr-05 May-05 J un-05 J ul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 J an-06 Feb-06 Mar-06 Apr-06 Average M T W TH FDemand 197 186 174 159 161 159 156 216 211 168 146 176 Demand 261 240 235 208 184Supply 171 179 195 179 201 176 164 192 174 150 118 173 Supply 193 190 162 195 175

S&D Average Weekly Averages

Supply & Demand

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50

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350

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Day of the Month

Demand Supply

Average Weekly Supply and Demand

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100

150

200

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300

M T W TH F

Demand Supply

Family MedicineSupply & Demand Daily Average by Month

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50

100

150

200

250

Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 Average

Demand Supply

Tracking Appt Demand and Supply source: YKHC, Bethel Alaska

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What’s your situation?How do you know?

D>S ? D<S ? D:S ?------------------------------------------------ “Our schedules are jammed every day. Our

Demand must outstrip our Supply”(??????) “We’ve had the same Delay for months.” “We measure D and S, continuously

and map the trends.”

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If Demand is Greater than Supply

1. Work harder ?2. Delay the work ?3. Buy more supply ?4. Do the work differently !!! …test….

Shape Demand Eliminate duplicate visits Care Team development; leverage the work Extend visit interval Promote Continuity Max Pack Simplify Appt types and times Nurse Appts, phone appts, group appts. Improve Access to reduce No Shows and capture that

Supply Spread

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Identify source of Demand and ask, “Why?” Internal External Discontinuity Single issue visits to ramp up visit

count? Bumping Delays and defensive booking Growth

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If Supply is greater than Demand…

Opportunities Backlog reduction easier Growth

Challenges Over supplied if growth not possible Financial impact

2. Reduce the Backlog2. Reduce the Backlog

Are we there yet?


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Good Backlog vs Bad Backlog


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Backlog Planning

• Assemble your team• Develop a written plan• Set two dates• Who plays???


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Backlog Reduction

No substitute for hard work, but…


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Backlog Plan: Smart Strategies Work backlog as a team

Look ahead at the schedule

Maximize the visit efficiency

Extend visit interval

Manage follow up visits in a different way

Leverage the work to others

Support the team during backlog redux.

Celebrate!!!!!© Tantau & Associates copyright Tantau &

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Set Two Dates…

Select a start date

Select an end date

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Do Increasingly More Of Today’s Work Today

Commit to it!

Don’t add to the end of the queue

Loosen the criteria for “today”


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Work Backlog As A Team

Commit to continuity for appts

Can someone else on the team manage this problem?

Beware of Negative Reward


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Look Ahead At The Schedules Check for duplicate visits and

referrals…comb the schedule.

Will a telephone call suffice? Phone appts? SF General Family Medicine testing

Can more be done at today’s visit to eliminate a future visit?


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Consider This… A physician sees twenty patients a day for

twenty days per month for ten months per year. If s/he is able to maximize one visit to reduce future demand, then this physician has saved 200 visits in a year. That is ten physician days.

If a physician can appropriately extend the visit interval for fifty diabetic patients from three months to four months, then fifty visits are saved per year. That is 2.5 physician days.

Better yet, use members of the Care Team!© Tantau & Associates copyright Tantau &

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Maximize Visit Efficiency Increase the value of the face-to-face

clinician/patient time

Eliminate distractions / interruptions

Leverage the providers time (OE)

Do more with some visits


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Extend The Visit Intervals Specific patient

Specific diagnosis or care pathway

Eliminate or combine certain return visits


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Manage Follow-Ups In A New Way

Can an RN or Health Coach follow-up with the patient?

Can an NP or PA manage the care plan?

Phone visit follow-up? Group visits? Tickler file reminder vs appt?


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Third next appointment -PT

0

5

10

15

20

25

30

35

40

RH

KH

HJ

Sometimes a small change can make a big difference…YKHC Physical TherapyReduction in Delays for Appointments

Date

No. of Days

Stopped serialBooking of returns


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Hard Strategies

Temporarily add daily capacity How much, where, when…

Do increasingly more of today’s work today…add less to end of queue

Identify team members roles and responsibilities…


Hard Backlog Strategies

Add daily capacity

• Where?• When?• How?• Some customization is good.• Be clear!


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Temporarily Add Capacity

Not too much…

Not too little…

Just right!


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Thoughts To Consider… Promote team communication…daily

huddles, standing agenda item.

Collect data, analyze it, talk about it, share it.

Gain commitment

Support the team

Motivate the staff

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Cautions… Backlog reduction is hard work Prepare for effects on other services Be careful about “rewarding” the

early birds with perverse incentives Beware the temptation to slide

backwards when things get a little better or worse!


BACKLOG REDUCTION

Describe Actions Point Person

Timeline

Develop a Plan

Set Start Date

Set End Date

Identify special needs

Backlog Budget ?

Add Capacity daily

Smart Strategies

Look ahead in schedule

Maximize visit efficiency

Establish panels

Promote continuity

Incent/Support the team

Use technology

Communication plan

Track and display metrics

Celebrate milestones


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Example from Swedish Health Care System

Nurse-Managed Clinics in charge of schedules, all follow-up visits, searched for every opportunity to remove work from specialist

Standardized protocols and pathways beginning with ER (most of their cases came from ER)

J onKoping Dept of Internal Medicine Neurology

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Day

s__r


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Annotated Run Chart – Medical College of WI

Visit Access -3rd Next Available Appt

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4/25

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5/9/

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6/6/

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1/05

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9/05

Day

s

New Appts. F/U Appts.

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1. Extended visit intervals based on actual availability and clinical need2. Summer vacation with no contingency plans3. New provider began to see patients, Dec. 1

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PDSAs: The Wisconsin Experience

1. All patients leave clinic with an appt based on real supply-

looked at 3rd next, extended visit intervals where appropriate, considered phone follow-up in place of visits, need for tailored follow up plans

2. Every patient leaves with a follow-up plan


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Third next appointment -PT

0

5

10

15

20

25

30

35

40

RH

KH

HJ

YKHC Physical TherapyReduction in Delays for Appointments

Date

No. of Days

Stopped serialBooking of returns


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3. Decrease Appointment Types• Times = Types• Decrease variation

-Increase flexibility• Sorting and Matching• Qualifying criteria• Too complex? Never get it right!!!!

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Standard Appointment Lengths

• Queuing; Grocery Store vs Bank

• Leveling for all the system

• See work in the whole system - Triage for appts

• What patients tell the agent• What staff tell the lab!

• Likelihood of staying on time

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Queuing Options… The Bank


Grocery Store


More appt types and times … More lines Less reliability More complexity Longer waits More fudging More Tension More chaos


Multiple Times = Multiple Types

3 types or 3x4 types???? Different definitions for each PCP? Customization difficult to manage New providers; hold every other

appt rather than create new types Over booking and double booking

reduce actual time for appt



“I love my schedule template. I just can’t remember the last time I had a day when patients were scheduled

that way!”-Steven Koop, MD

Gillette Children’s Hospital

Common issues…. Caps on certain types of appts

WCC, WWP, Physicals, others?

Squeezing 8 hours of work into a 6 hour day; “No more appts booked after 3 pm because we always run

behind.”


Best examples in Primary Care

One, average appt length Next best: all “shorts” with a few well

defined “longs” Scooping 2 shorts to create longs

Idea! Measure actual face to face time with

different appt lengths Test 1 session with 1 PCP with an average

appt length


So, what’s next???? Best ideas….. Plans to meet…. Organize Backlog Plan…. Simplify appt types, times, templates Keep measuring Delay, Demand, Supply

and Activity What else…..? More to follow….the rest of the strategies.


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Advanced Access: How To Make it Work; Part A Catherine Tantau, BSN, MPA Tantau & Associates P.O. Box 179 Chicago Park, California 530-273-6550 [email protected].

Documents

total demand slide

activity slide

external tantau associates

mpa tantau associates

true demand demand drivers

demand true demand formula

dimensions demand

provider measure demand