This is part 2 of a 3-part series on how to implement ‘Advanced Clinical Access’, created by Dr. Mark Murray. This model is based on the principle of Equilibrium, that when healthcare service Supply and Patient Demand are equal, excess downtime and delays can be eliminated from the system. This can be achieved by removing the division of Patient Demand (into either Urgent or Routine), which creates two separate queues for different types of patients. Removing the queues within Patient Demand removes the delay within the system.
An Advanced Clinical Access System is designed to eliminate wait times by managing the total resources who provide care. When resources are optimized and managed effectively, capacity is created. In an optimal system, you provide enough capacity for services to meet the demand of your population at the time it occurs.
It can be difficult for healthcare organizations to implement this improved Access System with their existing resources but there is help available.
In this article we’ll cover the 2nd Strategy and steps 3-5 of the Advanced Clinical Access process to achieving a balance between Healthcare Supply and Patient Demand.
Pragmatic Solutions to Understand Supply & Demand and Plan for Contingencies
Supply and demand are highly predictable and despite common perceptions, are finite. An improved Advanced Clinical Access system uses these predictions to build a rational method for responding to the needs of patients.
Learning to understand patient demand for appointments, advice, or messages to providers has been found to be accurately predictable based on population, scope of the provider’s practice, and, over time, the style of the provider.
Know Your Demand
The only way to determine the true demand is to measure it. True demand is the total number of patient requests received on any given day by both internal (return visits generated today) and external sources (phone calls, emails, walk-ins, etc.)
Know Your Supply
Supply is the total resources available to a clinic. This includes staff, equipment, exam rooms, offices, etc. When the total resources are well coordinated, capacity can be created. Capacity is the total hours of clinician time devoted to appointments.
For specialty care, it might be difficult to get a good overview of available supply as specialists may only be present on specific days or concentrate on specific procedures or conditions.
In this case, it might be helpful to create a monthly calendar to track system-wide schedules and availability of providers.
Do Today’s Work Today
Once true supply and demand are known, a course of action can be determined. If a mismatch is shown, where Patient Demand exceeds resources available, then steps need to be taken to create an equilibrium within the system. If the overall demand and supply patterns over weekly and monthly trends appear to be in balance, clinics can choose one of two methods to respond to or absorb Patient Demand daily:
a. Carve-Out System
A carve-out system holds some appointments each day in anticipation of same-day demand. While this method may help initially to meet daily demand, it constrains the system. Holding some appointments each day closes available slots in the future, meaning some demand will still be put off into the future with patients given appointments on another day.
b. ACA System
An Advanced Clinical Access system takes care of each day’s demand on the day it is generated. The only appointments scheduled at the beginning of each day are return appointments generated at the provider’s discretion or patient preferences. This provides maximum flexibility in the system to absorb daily demand.
For specialty care, there may be a necessary gap between the time the demand is generated to the time the patient is seen to allow for tests or procedures required prior to the appointment, or due to the geographic distance between the patient’s primary and specialty care clinics. This gap might be reduced by coordinating testing and procedures with support or ancillary services, and by using direct booking from primary care.
Equitable Panel Sizes
An equitable panel size, based on clinical FTE, ensures the physician will be able to offer quality, timely care to a reasonable number of patients. A designated panel size assures the provider that the demand for services will not exceed his or her capacity to provide them. In an Advanced Clinical Access system, equitable panel size is an outcome of good panel management.
In an Advanced Clinical Access system, determining an appropriate panel size is an outcome of good panel management, but is only one factor required to fully understand supply and demand.
Establish Input Equity for Specialty Clinics
Specialists will not technically manage a panel of patients in the same way as primary care providers because patient assignments are based on referrals. Input equity means that new patients will be assigned to specialty providers based on set factors, like current patient volume, and scheduled time in office.
A large range of appointment types increases delay in the system because each appointment type creates its own differential and queue. For example, if a nurse practitioner only takes physicals on Tuesday afternoons, a patient requiring a physical may have to wait several weeks until a Tuesday afternoon appointment slot becomes available. Additionally, each appointment type requires its own criteria to determine which patient applies to which appointment type. The greater the number of appointment types and evaluation criteria, the more time is required to enter patients into the queue.
In a clinic utilizing a carve-out system, several appointment types might be standardized, such as urgent or same-day vs. routine or future appointments. While this carve-out system introduces more flexibility into the system, an Advanced Clinical Access system makes no distinction between urgent and routine appointments. In primary care, the only distinction is between “Provider Present” and “Provider Absent”. In specialty care, there is differentiation between “Consults, Routines, and Returns” and “Procedures”, appointments requiring special room set-up or equipment.
Reducing appointment types simplifies telephone appointment triage, allows for more flexibility for patients, and reduces queues. For the most flexibility in scheduling, standardize appointment lengths that can be utilized singularly or combined, such as combining two 15-minute appointments to assist a patient who has complicated issues. This way, times for longer appointment do not need to be predetermined for certain days and can be applied as needed.
Even when the supply and demand in a clinic are balanced, there will be times when demand outstrips supply. Fluctuations in demand can be expected (e.g. flu season) or unexpected (e.g. many walk-ins on one day), just like expected and unexpected variations in supply (e.g. vacations or sick leaves).
While a traditional system relies on patients to absorb the consequences of the inequality between supply and demand by waiting longer for service, clinics utilizing Advanced Clinical Access have contingency plans that shift the variation of responsibility from the patient to the provider.
Manage Demand Variation Proactively
To manage variation in demand, the clinic must first know its general patterns of supply and demand. Understanding these patterns allows the clinic staff to predict and anticipate where variations may occur.
Once the real patterns of supply and demand are known, the clinic can plan to add more capacity for times based on predictions, like cold and flu season in January and February.
The increase in demand can be anticipated and arrangements made ahead of time for nurse practitioners to add appointment times to their schedules during these peak periods.
For days when supply is greater than demand, clinics can have agreed-upon assignments for staff, such as team meetings and inventory checks, to ensure staff time is used productively.
Develop Flexible, Multi-Skilled Staff
The flexibility of the staff to adjust their responsibilities during expected or unexpected surges in demand is a major component in the ability of a clinic to respond. Some clinics have a ‘float person’ that is trained to cover duties throughout the clinic when required.
Anticipate Unusual but Expected Events
Some situations occur relatively infrequently, but not completely unexpectedly. To prevent every situation from being treated as a surprise and causing disruption in the normal flow of the clinic practice, agree on standard protocols for each event and detail clear responsibilities of each staff member during these times.
Our healthcare team has the required experience to design and implement healthcare solutions with you that deliver value for both patients and your healthcare team. Send us your questions or challenges to begin the discussion on what’s possible.
Next up – Strategy 3 – Redesigning Your Healthcare System to Increase Supply
Pragmatic Solutions to Manage Constraints, Optimize Care Teams, and Anticipate Patient Needs (Steps 6-10).
In case you missed the first part in this series see the link below
