Advanced Clinic Access: Current Challenges Adapting to New Demands

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Advanced Clinic Access Current Challenges
Adapting to New Demands

• Presented by Renee L. Parlier, RN, MPA
• Director, VHA Advanced Clinic Access Initiative
• To
• Integrated Ambulatory Care Conference, June 25,
  2003

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VA, we have a problem!
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Primary Care Waiting Times and Number of Unique
Patients
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Results-Waiting Times
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Results-Summary

• From FY2000 FY2002
• Absorbed approximately 900,000 new patients (24
  increase)
• In September 2002, there were 282,872 patients
  reported on the VHAs Waiting List Survey
  (includes new enrollees as well as patients with
  appointments scheduled gt 180 days out)
• Less than 2 increase in staff (FTEs/1,000
  decreased from 46.9 to 38.7)
• No shows decreased from 14.2 to 12.8
• Notably reduced waiting times

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Problem of Access

• Waits and delays divert the publics attention
  away from the VAs quality story
• Dissatisfied patients, providers, staff
• Waste and inefficiency

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A problem of access

• An access problem is a delay problem
• When care is delayed quality suffers
• A delay problem is a systems problem
• Systems can be fixed

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Advanced Clinic Access

• An initiative being implemented to reduce wait
  times and improve veterans access to quality
  health care
• Enables the patient to receive the care he needs
  from his provider at a time convenient to the
  patient
• Do todays work today

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Supply and Demand

• In health care, every day, all day long, one
  patient at a time we match supply and demand
• We can do it well or we can do it poorly
• But we cant not do it.

• ACA gives us principles to design a system
  without wait and without waste.

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• Background Theories
• Womack Jones - Lean Thinking
• Murray and Tantau - Advanced Access
• IHI/IOM - Collaboratives/Standards
• NRC/Picker - Patient Centered Care

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Traditional Model

• saturated schedules
• overbooks
• very little flexibility
• dissatisfied patients and staff
• multiple appointment types
• overflow
• high anxiety
• high cost

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Carve Out Model

• Frozen appointments
• Filled appointments
• No room in schedule for routine and non-urgent
• Steal from the frozen appointments
• Tell the patient to call back on the day the
  appointment opens up

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Tyranny of the urgent

• acute symptoms and concerns crowd out less urgent
  needs resulting in lack of attention to chronic
  disease

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Service Requests
Phones chaos Triage cycles Rework Dissatisfaction
Discontinuity Despair (No show)
D
DEMAND
SUPPLY
S
Major Insight D S
Appointments
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Every system is perfectly designed to get the
results it gets
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Insanity is doing the same thing over and over
again and expecting a different result
Einstein
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Critical Design Elements

• DS
• Continuity/Familiarity
• When the patient needs it
• Coordination of care between primary care and
  specialty
• Management of the panel and not visits
• Max-packing
• Plan-do-check-act
• Rapid cycle change
• Measurement
• Team oriented
• Leadership commitment
• Will to change

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Strategies for Achieving a Sustainable System for
Patient Access
Strategy 1 Shape the Demand
Strategy 3 Redesign the System
Strategy 2 Match
Supply and Demand
F. Manage the Constraint G. Optimize the Care
Team H. Synchronize patient, provider, and
information I. Predict and anticipate patient
needs at time of appointment J. Optimize rooms
and equipment
C. Understand Supply and Demand D. Reduce
Appointment Types E. Plan for Contingencies
A. Work Down the Backlog B. Reduce Demand
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True Demand

• Total appointment requests (regardless of what
  day the appointment is actually assigned)
• Total number of walk-in requests
• Deflections (to urgent care/Emergency room)
• Total number of follow-up appointments generated
  today
•     
•  
•  

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Drain the lake work down the backlog

• Backlog is all the appointments on the future
  schedule for a particular clinic
• Its work put off into the future
• A clinic cannot successfully improve without
  getting rid of the backlog

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Ideal Office Practice 11 key elements
IHI Idealized Design of Clinical Office
Practice, IHI web site, www.IHI.org

• Focus on clinician-patient relationship
• Individualized access to care information
• Individuals control their care
• Minimal waiting
• Seamless transfer and communication of
  information and coordination of care

• Financial performance unhindered viability
• Real-time data measures of process,
  satisfaction, finance, outcomes, and epidemiology
• Continual improvement and waste reduction
• Individual health linked to community health
• Model work environment

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Misconceptions about Advanced Clinic Access

• Patients get whatever they want when they want it
• Demand is insatiable
• Talking about scheduling everyone same day
• Tell patients to call when they want to be seen
  leading to loss to follow-up

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ACA AdvantageDr. Gordon Schectman, Nov. 2002 PPT
Prolonging the RVI A means to implement ACA?
Results of the Milwaukee pilot

• Before
• Full provider profiles
• Overbooking
• Delays in Clinic
• Appointment delays
• Urgent care in ER
• Routine appointments

• After
• Many open slots
• No overbooking
• Patients seen on time
• Same day access
• Urgent care in clinic
• No routine appointments

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Advanced Clinic Access

• Pull the work toward today and it opens up space
  for tomorrow.

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Spread components

• Better Ideas
• Communication
• Social System
• Infrastructure

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Advanced Clinic Access (ACA) Initiative

• Social System
• Unit providers in six clinics
• Key messengers
• Listeners/Connectors
• Communities of practice
• Motivators and incentives
• Ability to adapt the changes

• Communicated
• Modes
• Purpose

• Better Ideas
• Case for ACA
• Description of ACA
• Transition materials

Infrastructure VISN Director, Clinical Manager,
Facility Director, POC as leaders - Staging
plan - Technical support - Knowledge
management - Measurement/Feedback
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Resources Available Website http//vaww.vhacoweba
pps.cio.med.va.gov/waitingtimes/

• Tool kit
• Service agreements
• Structured consults, templates
• List of 10 key changes
• ACA monograph
• Power point presentations

• Communication Resource Guide
• Posters
• Transcripts from ACA coaches (experts) conference
  calls
• Measures and data collection tools
• FAQs

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More resources

• Audio-visual
• Time Has Come video
• Advanced Clinic Access video with Mark Murray
• People
• National and local Coaches
• VISN and Facility Points of Contact
• Steering Committee members
• Steering Committee Liaisons
• ACA Director
• Communication
• Monthly conference calls with coaches
• Twice monthly conference calls featuring clinical
  areas
• Primary Care conference calls

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Primary Care National Access CoachesFabiane Erb,
ACA Steering Committee Liaison

• John Sanderson, MD, Buffalo
• Richard Stark, MD, East Orange
• Dan Castro, MD, Loma Linda
• Daryl Dickson, MD, CBOC, Rapid City, SD
• Luz Vasquez, MD, West Haven
• Mary Kim Voss, MD, Hampton
• Tim Dresselhaus, MD, San Diego
• Bonnie Rudolph, MD, Reno
• James Borland, MD, Jacksonville OPC
• Joyce Caldwell, Birmingham

• Brent Armstrong, MD, Amarillo
• Boyd Shook, MD, Oklahoma City
• Mary Lynn Allen, MD, Gainesville
• David Reagan, MD, Mountain Home
• Mark Stanton, MD, VACO
• Gordon Schectman, MD, Milwaukee
• Stephen Ezeji-Okoye, MD, Palo Alto

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Perseverance and Persistence

• In the realm of ideas, everything depends on
  enthusiasm.
• In the real world, all rests on perseverance.
• Nothing in the world can take the place of
  persistence
• Talent will notnothing is more common than
  unsuccessful people.
• Genius will notunrewarded genius is almost a
  proverb
• Education will notthe world is full of educated
  derelictsPersistence and determination are
  omnipotent.
• Calvin Coolidge

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Its not JUST about Waits

• Improving Quality
• Changing Systems
• Innovation
• Rapid Cycle change plan-do-check-act
• Satisfaction

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Dr. Don Berwick, President and CEOInstitute for
Health Care Improvement

• On VHA
• There is no organization more significant, with
  more potential, and more aligned with IHI because
  of what youve done.
• The work VHA is doing is the benchmark for large
  system change possibly worldwide
• The best in VA will be the new bar.

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• References
• Bodenheimer, Thomas, MD Wagner, Edward H., MD,
  MPH Grumbach, Kevin, MD. Improving Primary Care
  for Patients with Chronic Illness. Journal of the
  American Medical Association, October 9, 2002
• Gerteis et al. Through the patients eyes. San
  FranciscoJossey-Bass. 1993.
• ?Hows Your Health Online? (http//www.howsyourhea
  lth.com)
• ?Institute for Healthcare Improvement
  (http//www.ihi.org)
• ?Institute of MedicineCrossing the Qualtiy
  Chasm. (http//www4.nas.edu/onpi/webextra.nsf/web/
  chasm)
• ?Lionni, L. Fish is fish. New York Dragonfly
  Books. 1970.
• ?Murray, M, Tantua, C. Same Day Appointments
  Exploding the Access Paradigm. Family Practice
  Management, September 2000.

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• References
• ?Murray, M, Berwick, DM. Advanced access
  reducing waiting and delays in primary care. JAMA
  20032891035-1040.
• Murray, M et al. Improving timely access to
  primary care. JAMA 20032891042-1046.
• Nolan et al. The Improvement Guide A Practical
  Approach to Enhancing Organzational Performance.
  San Francisco Jossey-Bass, 1996.
• ?OReilly, C, Pfeffer, J. Hidden Value.
  BostonHarvard Business Press. 2000.
• ?Scholter, PR, Joiner, BL, Streibel, BJ. The Team
  Handbook. Oriel, 2001.
• ?Senge,, PM. The fifh discipline. New York
  Doubleday. 1990.
• ?Womack, JP, Jones, DT. Lean Thinking. Simon and
  Schuster, 1996.