PRIMARY CARE APPOINTMENT ACCESS

Reengineering the Appointment Process

When enrollment drops by 5%, and one third of those disenrolling cite dissatisfaction with appointment access, a health plan has a powerful incentive to improve. This health plan implemented a comprehensive approach to improving appointment access. It emphasized fundamental principles of operations management.

As early as 1993, this plan recognized that member access to primary care was a critical issue. A member survey in 1994 revealed that plan members were more dissatisfied with primary care appointment access than with any other aspect of care or service; only about half (55%) of the survey's respondents were "very satisfied" with access to routine primary care appointments.

The plan decided to focus on access to primary care and member satisfaction with access.

The target population consisted of all plan members seeking an appointment. Performance measures identified included percentages of members who stated they were ''very satisfied'' with appointment access and appointment wait times.

Satisfaction with appointment access was measured using a member survey. The survey was administered to a stratified probability sample of members. This sample was drawn monthly from each clinic's member base.

Appointment wait times were determined using the plan's appointment system. No sampling were used, all appointments were included.

Baseline satisfaction measures, derived from 1995 data, found the percentages of members were "highly satisfied" with various appointment types (see PARAMETERS and Table 1).

Benchmarks were based on standards used by a large health care benefits consultant. The benchmark for routine appointments was within five days; for urgent appointments, within one day. The plan set a performance goal of 70% of members being highly satisfied with days to wait for an appointment. The plan also set a performance goal of a wait time for urgent or symptomatic care of less than one day.

Before implementing interventions, the plan reviewed the results and comments from its member survey to identify barriers to access. The plan identified that the most significant barrier appeared to be the plan's triage system.

This system was actually designed to be a barrier; staff were concerned that patient demand for appointments could overwhelm the clinics. The system required that members who called for a visit first speak to a registered nurse. The nurse decided if an appointment was truly necessary, or if the member's need could be handled with telephone advice alone.

A study of the triage system showed that members who received advice rather than an appointment generally ended up getting an appointment within two weeks of the call. The triage process created a two-tier system. Members familiar with the system could get appointments easily, but those who were not, including new and relatively healthy members, often had difficulty.

Because barrier analysis had revealed that the triage system was the most pressing problem, the plan began its initial interventions with a push to reorganize this system:

• Triage nurses were assigned other tasks; advice was to be provided upon request of a patient, and not as a mandated substitute to an appointment
• The plan's staff simplified its appointment system codes; all symptomatic appointments were now called "same-day appointments," regardless of acuity level
• The plan implemented a policy that required primary care clinics to offer same-day appointments to members requesting them, no matter what their condition or acuity level

In addition, models were developed to better predict demand for same-day appointments. Each clinic site was charged with the responsibility of seeing that there was sufficient staff to meet demand for appointments, and for managing its own distribution and number of appointments. Each clinic was required to develop a system to handle overload appointments when supply was outstripped by demand.

In March 1996, the plan developed and implemented the Open-Access Report Card. This system gave a monthly status report to each clinic's manager, supervisor, and lead scheduler on how well each clinic was meeting daily appointment demand. The report provided useful feedback on how the process was working.

The first remeasurement used data from 1996. Results showed that the percentage of "very satisfied" members had increased for:

• Routine appointment access (60%)
• Urgent appointment access (71%)
• Test appointment access (53%)
• Days to wait for appointment (62%)
• Ability to see a provider when needed (71%)

Wait-time measures also showed improvement:

• Average wait for open-access appointments was 0.63 days - 34% better than baseline
• Average wait time for urgent, routine, and return primary care appointment was 5.8 days, a 30% improvement over baseline

The plan established an additional performance measure at two clinic sites: the percentage of childhood/adolescent physical exams seen within 30 days. This was determined from the appointment system. The baseline performance on this measure was established using 1996 data.

Baseline performance at Clinic A was 48%; Clinic B reported a rate of 61%. The plan established a goal to improve this measure to 80%.

Preparing for new interventions, the plan determined that three major issues remained to be addressed:

• The definition of urgent and symptomatic appointments needed to be more flexible; although centers were giving patients same-day appointments, patients requesting a next-day appointment were being told to ''call back tomorrow''
• The additional appointments being used for same-day services were negatively impacting access to preventive health care appointments
• Variation in the supply of open-access appointments made it hard to meet demand

The plan focused on these key issues during 1997: First, a software program which helped assess and manage appointment supply was designed and put into use. This program compared the predicted demand with the actual supply of appointments and alerted users when demand exceeded supply. Second, physical exam teams were created to improve access during summer peak time for adolescent and childhood physicals. The teams consisted of two nurse practitioners, a medical assistant, and a nurse to administer immunizations. The plan was able to perform twice as many exams per day using this system.

Third, a new policy was created to increase flexibility in scheduling same-day or next-day appointments at the member's request. The plan created health care teams at specific sites as part of a pilot project to test this concept. The goal was to share responsibility for an assigned set of patients and to allocate resources more effectively. A primary care staffing model was also implemented to ensure that staffing distributions were appropriate at all times.

INDUSTRIAL MODELS This plan adopted operations management techniques common in other industries. Mathematical models to predict demand are widely used by a variety of service industries; unfortunately, their use is less common in health care. Adopting methods proven to be successful elsewhere can help plans use their limited resources efficiently.

A PATIENT-CENTERED SYSTEM The fundamental changes that this plan made to its appointment system were not merely operational, they were conceptual. The original system was designed to meet the needs of staff, not of members. Focusing on patient requirements, not the desires of plan staff, was the critical first step in improvement. In order to get buy-in from staff, physician participation was critical. By including physicians in the initiative, a sense of responsibility and ownership for meeting the plan's patients' needs for care was developed.

Data for satisfaction from 1997 identified increases in all measures except access to urgent appointments (see chart below).

Wait-time measures showed improvements in most of the areas surveyed:

• Average wait for urgent, routine, and return primary care appointments was 5.5 days
• 72% of childhood/adolescent exams were seen within 30 days at Clinic A; 93% were seen within 30 days at Clinic B

Open access appointments, however, increased to 0.72 days.

The plan identified further barriers to improvement:

Substantial variations from clinic to clinic in appointment management and scheduling processes
• Lack of a well-established process to manage volume during seasonal peak times
• Inefficient management of staff workload and staff burnout
• Inadequate attention to physical exam access

After the 1997 data were collected and analyzed, additional interventions were based on refinements to already existing models of care. The primary care model, health care team, and physical exam team concepts were enhanced and expanded across the region.

Perhaps most important, the plan has continued to work toward improving access to primary care appointments. This quality initiative created a system that has now become a way of life for the plan's staff. The concept has become embedded in the scheduling process. When members call, standard operating procedure now involves granting their appointment requests.

Although the interventions used might not be easily duplicated outside a large group or staff model, all plans can address obstacles to appointment availability through continual efforts to improve.