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LCDR
Micah L. Meyers, MSC, USN, FACHE, Bureau of Medicine and Surgery Managed
Care, Education with Industry Fellow, TRICARE Mid-Atlantic Region 2/Humana
Military Health Services, Inc., Norfolk, Virginia
ORGANIZATIONAL
INFORMATION
The medical
clinic referred to in this case report employs 120 military personnel
and 46 civilian service personnel. Included in these numbers were nine
physicians and other providers who saw approximately 80,000 patients
annually. The clinic structure is a 61,000-square-foot building that
was built in 1967; it was originally used as an inpatient facility and
was therefore rather ineffectual for use as a modern ambulatory care
clinic.
This clinic
is a Navy shore-based military treatment facility providing primary
care, outpatient care, and case management to active-duty and other
eligible beneficiaries. It has been in operation for 34 years and is
owned and operated by the Department of the Navy. It is headed by a
commanding officer subject to the command and control of the responsible
line commander, commander of the Naval Air Warfare Command (Aircraft
Division), and the chief of the Bureau of Medicine and Surgery in Washington,
DC.
In the
20-mile radius of the clinic, known as the "catchment" area,
lived an estimated 112,000 beneficiaries. The clinic is located on a
U.S. Navy Air Station, and active-duty personnel and their family members
were the majority of beneficiaries served. Other beneficiaries from
outside the catchment area utilized the facility as it is located near
a smaller Navy clinic. Several large hospitals that are very broad in
scope are present in the area of the clinic. The nearest emergency room
is a civilian community hospital facility located 15 miles to the southwest.
The nearest military hospital having emergency care and inpatient facilities
was 35 miles north.
BRIEF
STATEMENT OF THE PROBLEM
The facility
under study had an internal department that was centrally organized
to see all primary care patients, known as the Family Medicine Clinic
(FMC), which then separately organized its patients into family medicine,
military medicine, and pediatrics.
The FMC
saw 55,000 patients annually on a walk-in basis. This was very inefficient
as patient waiting time could be as long as three hours in the height
of the flu season. The system raised not only customer service issues
but also health issues, as dozens of sick individuals had to be in close
proximity to others for prolonged periods. The other three clinics individually
appointed their own patients, so each had separate phone numbers; because
they were separated by distance the appointment clerks could not cover
each other over lunch and other breaks. The other driving force for
change was the imminent implementation of the TRICARE program in the
region, which virtually eliminated all walk-in clinics in favor of those
that appointed their patients.
DESCRIPTION
OF THE PROBLEM
Background
In this case study the term "open access" refers to the concept
of providing a same-day patient appointment (SDA) to military managed
care priority beneficiaries regardless of the type of complaint. Open
access is not to be confused with "walk-in." The Military
Health System and TRICARE are in a unique position to divest themselves
of incredible amounts of appointment inventory and the inherent cost
of maintaining that inventory, decrease unnecessary visits, increase
visit capacity, and improve patient-physician relations and patient
satisfaction for access to care.
Studies
performed by health maintenance organizations have shown that for a
healthcare delivery system acquiring new patients is approximately seven
times more expensive than keeping current ones. This is the result of
the advent of marginal overhead costs associated with the following:
- Enrollment
costs (e.g., startup materials produced, education campaigns, marketing,
promotion)
- New
enrollees bringing their own prescriptions that are not on the organization's
formulary into the system
- Pent-up
demand
- New
members not knowing their own physicians, causing a need for time
to develop trust equilibrium between the physician and patient so
that care provisions are agreed on and followed
Currently,
three major types of appointment access system approaches are in place
throughout the Military Health System:
- The
"saturated" or "full-triage" approach: Patients
who call in that day for SDAs based on a category description compete
and win out over other patients who do not meet the definition of
acute care. The schedules that are full for a month become even more
saturated as patients are continually being moved back on the priority
list and seen at a later time. Over time this develops what is known
as the patient "inventory."
- The
"carve out" approach: The space required to see patients
is predicted and systematically "carved out and protected"
or held for today's and tomorrow's urgent cases. This approach also
contains triage components. In this approach problems develop as the
urgent and routine cases are stratified, and the resulting inflexibility
causes patients at the end of the routine line to get pushed out farther,
thereby eating up capacity. No space for intermediate cases is often
available. Appointments carved out for the stratified targets cannot
be "stolen back" to benefit the routine cases and relieve
the inventory burden, which similarly plagues the saturated approach.
Some military treatment facilities have had to resort to booking groups
of SDAs ahead of time and then turning them into routine and follow-up
appointments.
- The
"open access" approach: In this nontraditional approach
only two conditions exist: an appointment occurring "today"
and an appointment that is to occur "other than today."
The patient is asked two questions: (1) Do you want your appointment
today? and (2) If not, when do you want your appointment? In this
approach the patient rather than the schedule controls the appointment
making. This approach also demands that the healthcare delivery system
integrate an empanelment process for their enrollees so that when
a patient agrees to be seen that day after calling in with their complaint,
an assigned team of providers who will see that patient has already
been coordinated.
The open
access approach is not an intuitive one because it removes all barriers
previously considered necessary within the Military Health System, such
as triage, which has been held as a way to maintain fairness of access
of for all beneficiaries. In reviewing such a reengineering of business
practice, if one considers making a minimum of 60 percent of all patient
appointments same-day only and the military treatment facility sees
all those patients that same day regardless of complaint, priority enrollees
would not want to go anywhere other than the military treatment facility
if they can see their doctors when they want to see them. This approach
effectively places the patient in the driver's seat, and the only appointments
being shifted to other than today are done so based solely on patient
or provider choice.
Appointment
Category Management System
Under the region's current TRICARE managed care contract business rules
of appointing, category descriptions of patient visit types drive how
and when the patient is to be slotted into a military treatment facility,
which complements the rules of access. Currently, an SDA is loosely
defined as for acute patients who need care the day that they call combined
with how that acuity is described over the phone to the person booking
the appointment. With this reasoning a blood pressure follow-up is not
considered worthy of an SDA. However, as these types of routine appointments
begin to compound themselves over time and as the backlog of patient
inventory exists, continual stress is placed on the healthcare delivery
system, effectively forcing frustrated patients to seek their various
levels of care outside the military treatment facility. With any appointment
category management system the key to success is getting rid of the
patient appointment inventory backlog that gets regularly deflected
forward from month to month.
The
New Initiative
At the Naval medical clinic in this case study the leadership took a
strategic look at what was being experienced by both patients and providers.
I was assigned as director for administration, the central administrative
executive whose position was devoted to complete support of the clinical
mission to provide improved access to outpatient ambulatory care. The
main organizational leadership body, of which I was part, is known as
the executive steering committee and is made up of leaders of clinical
services and the executive and commanding officers. The initiative to
develop a new way of increasing access to care was first made known
to the organization by the senior physician, who had attended conferences
of the Institute for Healthcare Improvement (IHI), and I took on the
responsibility of executing operations to make preparations. I reported
to the executive steering committee to provide updates and progress
reports.
Our patients
experienced: (1) feelings of dissatisfaction and (2) delays in making
and getting their appointments. Patients were not able to see their
primary care managers (PCM) on a consistent basis, the clinic kept running
out of appointments, phone access was a problem, and patients had to
work outside the rules to get seen. Our providers experienced: (1) dissatisfaction
in their work, (2) an inability to see their own patients consistently,
(3) chaotic patient scheduling and long days, (4) attempts to juggle
appointment templates, and (5) concerns with clinical capacity.
In April
of 2000, we decided that changing from a provider focus to a patient-centered
organization was necessary. The goals were to improve patient and provider
satisfaction, reduce delays in getting appointments, improve patient-to-PCM
continuity, reduce unnecessary work, and increase patient loyalty to
our brand of services.
ADMINISTRATIVE
DECISIONS
Following
numerous studies of current population data and appointment utilization
figures and through consultation with Dr. Mark Murray of Murray, Tantau,
and Associates, the leadership chose the date to which all providers
would work to reduce and eliminate any backlogged inventory of appointments.
Complete buy-in from all providers within the organization, including
senior physician leadership, was secured before any first steps could
begin.
Procedural
and Strategic Steps
Leadership provided the will to change and goals to be achieved and
ensured that organizational oversight was present.
Will to
change was enacted and demonstrated through securing the services of
Mark Murray of Murray, Tantau, and Associates, who have made great strides
in improving appointment systems and access to care to healthcare organizations
throughout the Unites States and Europe. They are closely affiliated
with the IHI and were pursued by this command for their services and
expertise. Further organizational commitment was demonstrated by locally
funding their services by our organizational leadership. A three-day
retreat was organized to allow all providers to be involved in business
practice decisions to enhance buy-in for Dr. Murray's teachings.
Goals were
outlined and agreed on by physician providers as reasonable and reachable.
Organizational oversight on progress and operations was made by the
managed care region's lead agent, whose office was provided with weekly
updates and apprised of any changes in business practices that might
affect the managed care support contract.
The organization
had to implement operational actions in the way of choosing metrics
and data collection methods as advised by Dr. Murray. To develop metrics
and collect data the clinic had to devote full measure to empaneling
all of its enrolled beneficiary population to individual PCMs. An agreed-on
method and metrics for data collection were chosen as advised by Dr.
Murray.
Assessment
of current phone answering system technology was made, and additional
lines and human resources were made available. The organization then
had to find its own way of gaining capacity for appointments within
the system.
A full-out
effort to reduce appointment backlog was instituted with attention paid
to adding as many appointments to provider schedules and templates as
possible as well as reviewing already filled appointments for clinical
necessity. The simplification of provider templates was achieved through
reducing the number of appointment types from nine to three-acute, routine,
and procedure-and through scheduling and adhering to appointments lasting
only 20 minutes each. Reduction of demand for appointments was initiated
through the use of critical paths, redefining follow-up intervals, and
maximizing use of each visit to reduce or eliminate unnecessary additional
appointments.
Contingency
plans needed to be developed to account for planned or unplanned losses
of providers or sudden surges of patient demand. Experiential paradigms
had to be exploded, such as fears of patient overload during heavy periods.
In Dr. Murray's words, "The unexpected is predictable"; if
we knew, for example, that flu season was coming by an estimated date,
we could adequately plan for and meet the demand that would be created.
Physician
coverage for other PCMs when they were sent on additional duty, travelling,
or on leave had to be established, agreed on, and practicable. Pre-
and postvacation scheduling had to be developed so that PCMs were effectively
"weaned" off and on to their schedules so that they did not
feel overwhelmed when returning to work from holiday or leave periods.
The "ramping down" period began two weeks prior to the PCM
going on leave, and the "ramping up" would occur for a two-week
period when they returned. Time-off policies for PCMs had to be decided
on, adhered to, and enforced by senior physician leadership. PCM/provider
teams had to look ahead on their schedules and calendars on a regular
basis to coordinate upcoming events that could affect their abilities
to see patients.
The clinical
organization had to devote the appropriate and necessary resources to
ensure the success of this program. PCMs were made accountable for their
panels or assigned an enrolled population through regular monitoring
by senior physician leadership of individual workload, patient-physician
continuity, and patient satisfaction metrics.
Office
efficiencies were realized through the elimination of unnecessary stovepipes
in the organizational structure and reporting chains and the appropriate
division and delegation of duties and responsibilities to the appropriate
staff. In other words, administrative staff was focused on administrative
types of work only, and clinical support staff was freed to perform
and assist solely with clinical duties.
Communication
with internal staff, our enrolled beneficiary population, and our stakeholders
was crucial to ensuring a coherent and consistent program. These actions
served to demonstrate a commitment to the new way of appointing and
support for the staff to take action and learn from mistakes without
fear of blame or criticism.
Initial
communication with beneficiaries was limited at first to flyers in military
base housing, articles within the local newspaper, and conversations
between PCMs and patients during visits. Further institution of the
new appointing system required consistent support and practice by the
internal staff.
Scripts
had to be developed for the internal staff to refer to in case they
became at a loss for answers to patient questions and to provide a unified
message of instruction to the beneficiaries to promote trust and confidence
in the new system. Regular internal e-mail communication among the staff
detailed specific problems encountered, and ways to troubleshoot and
correct these problems were shared on an e-mail list server that included
Dr. Murray as an online discussion participant and consultant.
Our stakeholders,
the Navy Bureau of Medicine and Surgery, the region's TRICARE lead agent,
and representatives from the managed care support contractor were also
kept up to date with developments and progress as well as with any difficulties
or setbacks encountered. All actions taken within the Naval Medical
Clinic appointing system were made in concert and coordination with
established policy and procedure and with contractual obligations for
both government and contractor to the greatest extent possible. The
data collected during the initial efforts are shown in the figure below.
The overall
empanelment or assignment efforts were a combined effort of family medicine,
pediatrics, military medicine, aviation medicine, and their individual
providers. Initially and throughout the process the assignment of patients
to a PCM was of utmost importance and crucial to success. Maximum PCM
assignment is necessary for patients and providers to develop the relationships
necessary for enhanced satisfaction, care continuity, and preventive
healthcare, all of which ultimately form the basis for reducing unnecessary
appointment stress on the system.
Measuring
the true demand was key to developing an assessment of capacity or the
actual workload being seen by the providers, including all those patients
who sought appointments but for any number reasons either gave up and
went to an emergency room or acute care center or who presented for
acute and nonacute reasons alike. Obviously these data were very difficult
to collect, but by July and August of that year a reasonable picture
was beginning to form. Family medicine's assessment of its own true
demand for the month of July is shown in the figure below.
An overall
sampled clinical study of the overall true demand of the enrolled beneficiary
population for the month of September of 2000 is shown in the figure
below. Demand was measured as all calls or walk-in visits of beneficiaries
requesting an appointment regardless of the level of acuity as described
by the caller. The according number of appointments actually made for
that day was contrasted against the number of patients who actually
materialized and were seen in the clinic for an appointment. The spaces
in each day between the number of appointments made and the number of
appointments actually seen in the context of all demands on the system
were the basis for measuring and predicting the capacity each provider
could reasonably add into his or her schedule. This creates additional
access to appointments should they be needed by any new patients. This
tool served as a method of developing prediction models for open access
on a weekly or monthly basis.
Provider
and Patient Continuity
As previously discussed, enrolled beneficiary assignment to PCMs by
name was essential for systemwide integrity for open access. Additional
support care and appointments were managed or seen by each respective
PCM's team members, made up of nursing and physician assistant staff.
Continuity in this context is defined as those patients or percentage
of patients assigned to a PCM by name who were actually seen by that
PCM consistently over time. This tool is a method of checking performance
by individual clinics and teams to determine whether they are truly
keeping their assigned patients within their teams or "farming
out" their assignees to take an appointment with another PCM or
team because of failure to maintain their own capacity of open appointments.
A one-year study of performance from October to September of 2000 is
shown in the figure below.
The crossover
seen in June of 2000 is particularly interesting in that it illustrates
that the percentage of patients who were seen not necessarily by the
PCM himself or herself but by that PCM's support staff (nurse or physician
assistant) was reduced as the PCMs began personally seeing more of their
own patients; at the same time numbers of patients being deflected to
other PCM teams took a substantial downturn.
Reduction
of Backlog
The concurrent steps to be taken were for each provider to complete
the reduction and elimination of appointment backlog. This technique
is also known as determining the "third next available" appointment,
wherein the provider office looks ahead to three days before the next
appointment becomes available initially to assess the "cushion"
available to begin reducing the number to one rather than attempt to
reduce every appointment to the same day at the outset, which invariably
results in frustration, disappointment, and ultimately failure.
The third
next available appointment for the entire FMC is shown in the figure
above. For example, on July 8, the third next available appointment
measured on that day was averaging 2.2 days. This was a measurement
goal that enabled the clinic to begin fine tuning its practices to get
the number of backlogged appointments down. In contrast, the above figure
shows the measurements made by an individual provider within the FMC.
As can be seen, the variation in appointment availability was very wide
and varied greatly among providers. Gaps created by leave or temporary
duty periods resulted in patient loads transferred to another PCM.
Fortunately,
appointment wait times were only averaging approximately four to five
days in family medicine and two to three days in pediatrics. Having
Dr. Murray and associates provide training and an implementation plan
one week prior to start of operations ensured that all providers and
staff were on the same sheet of music and understood concepts involved.
Marketing of our plans to start an open appointment plan was begun through
printed advertisements throughout the military base housing areas and
in the local base newspaper.
The physicians
all agreed to work to eliminate their backlog down to one-day access
by a target period at the end of July. When that day arrived all providers
had more or less succeeded in having a one-day wait time for appointments,
translating to SDA. The trick was to hold the gain and begin the processes
to keep the flow moving through strict adherence to 20-minute appointment
times, ensuring that "today's work was done today" by making
sure all patient needs were met within that appointment, and eliminating
the need for unnecessary follow-up appointments. Metrics were also maintained
to track progress and were regularly reviewed by providers and their
support staff.
Support
Considerations
To ensure the flow of appointments was being adequately and properly
managed we agreed that each individual provider/PCM must have a minimum
of two examination rooms, one to two nurse officers to provide coordination
and support, and a minimum of two hospital corps technical staff to
provide advance preparation of examination rooms, retrieval and processing
of patient medical records, and so on. Such medical optimization practices
had been begun as early as the previous year, but application of such
practices proved to be a perfect and necessary fit for open/advanced
access appointing. The clinic itself had been recently remodeled to
enable adequate examination room availability, and staff support had
been realigned to give primary priority assignment to providers/PCMs.
These groups became primary care management teams, which functioned
in a coordinated manner to provide 24-hour-a-day contact with their
assigned beneficiaries. A beneficiaries could contact his or her PCM
or nurse manager at any time to discuss needs on a one-to-one basis
and arrange for an appointment that day or the following day, or possibly
negate the need for an appointment at all.
RESULTS
Wait
Times
As can be seen in the following measurements from June/July through
October of 2000 access or waiting time for appointments was significantly
decreased to the point where the overwhelming majority of appointments
were being made in the same day. A linear progression further highlights
the dramatic downturn in overall wait times for appointments.
Percentage
of Open Appointments Achieved
These numbers
show a great deal more variation as was expected during the first year
of implementation. The percentages were created from the number of true
open appointments available for patients through efficiencies created
from the new business practices out of all bookable appointments. Certain
days with an almost completely open appointment schedule were balanced
by days of heavily booked appointments.
Moderate
success in only four months is most certainly evident in the analysis
of the overall performance in looking at the appointment summary of
the FMC for the months of July through October of 2000. However, much
more tracking and maintenance of these measurements are necessary in
order to see how small these variations prove to be two to three years
hence.
The numbers
of patients who failed to keep their appointments, "no-shows,"
tended to play some havoc with clinics' abilities to maintain and predict
their capacities. The percentages of patient no-shows between February
and September 2000 are illustrated in the figure below.
DIFFICULTIES
ENCOUNTERED AND LESSONS LEARNED
Lack of
a steady state in the number of providers assigned to the clinic itself
was a problem. As military physicians were transferred, subsequent handling
of the departed provider's assigned patient population had to be taken
on by the providers left behind during the period in which the clinic
had to wait for a new provider to arrive. The additional load of patients
caused a perceived strain on the resources of those providers left behind
as well as a backlog of patient appointments appearing as the newly
arrived provider overcame the learning curve of advanced access procedures.
Patient
population was still not fully assigned to individual PCMs at the time
of implementation of open access. As such, some patients calling in
for an appointment required assignment to a PCM before booking into
a provider slot, a cause for some delay, as well as the time investment
required by the provider to learn the patient's history.
Outside
the scope of local operations of the Naval medical clinic but within
the regional managed care contract agreement the managed care contractor
maintains a centralized appointing office in a nearby city. The clinic
decided to maintain local control of booking local appointments while
leaving the option open for its beneficiaries to call a toll-free regional
number to reach the centralized call center for a remotely booked appointment
at the clinic. At that time the clinic was making approximately 80 percent
of its own appointments, and the contractor made 20 percent. The contractor
had the ability to book into the future any patients who called using
a 1-800 number and who were not assigned to a PCM. Even if the patient
was already assigned to a PCM and a spot was available with a differing
provider, the contractor could still book an appointment with the different
provider if the remote appointment clerk could see no other openings
in our local schedules. Ideally, in a successful open access environment
a problem such as this would not exist as there would always be local
openings, but we were not at that point yet. What seemed to be keeping
the new system of appointing robust was that we were still scheduling
80 percent of our own appointments. Managed care contractors did attempt
to comply with the local design of only three types of appointments
instead of the regionally accepted number of appointment types and instructed
their central appointment clerks to cooperate with the local staff to
meet the intent of the open access initiative; we met with relative
success and incurred no additional cost to the government.
The locally
purchased and operated automated phone-answering system was inadequate
for the volume level of calls being received. Aside from the technical
difficulties and feature problems experienced with the system itself
were military base phone office interface problems, some of which were
overcome. After a flow-chart study of processes, we added additional
staff devoted to manning and answering the eight individual phone lines.
This response aided and eventually resulted in less patient complaints
about getting through. Replacement of the phone-answering system is
a must. Some of the nurses on teams had patients call them on other
lines to get them in.
Communication
down to the junior staff member level is still an issue. When new problems
crop up, staff, including the PCM teams, sometimes slips into the old
solutions, creating consternation and confusion for provider and patient
alike. An effort toward including open access in the organizational
orientation is being planned.
Additional
lessons learned were that more scripts to guide the internal staff were
needed, the staff had to further agree on a more consistent policy for
managing clinics, and the fight against old habits had to be reinforced.
Tendencies toward backsliding were always in existence. Listening to
the internal staff and implementing their ideas proved to be very valuable
and were taken on in the development of policy. At this time the Naval
medical clinic is still using the open access appointing system and
is working to replace its phone-answering system, which has proven to
be the most difficult roadblock to overcome.
Source
The sole
source of information was the knowledge and experience of the staff
involved in this project.
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