This is the final article of our 3-part series for 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.
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.
Pragmatic Solutions to Manage Constraints, Optimize Care Teams, and Anticipate Patient Needs
It is a typical characteristic of a system to have constraints. A constraint, or bottleneck, is anything that restricts the flow of patients into and through the clinic system. These occur when your demand for a particular resource, such as a room or a certain test, is greater than its available supply. Managing the constraint correctly can increase the flow through your system.
Evaluating your demand against the capacity of each resource seems the logical manner to identify the constraints. They may, however, not truly be equivalent because they can be masked by constraints in other parts of your system.
Instead, look for signals within the system that identify a constraint:
Generally, it is expected that the primary provider is the constraint, but that may not always be the case.
While there may be several constraints in your system, there will always be at least one that is known as the “rate-limiting” step. This is the step that determines the true rate at which work passes through the system. This is the constraint with the most valuable and scarcest resources.
The rate-limiting step should never be idle, ensuring that work flows smoothly through it. Therefore, the focus should be on improving the capacity of the rate-limiting step, and not on optimizing every resource in the system.
For example:
In a clinic setting, the primary provider is likely the rate-limiting step, because they complete tasks that uniquely add value to the system. Any work that the provider is doing that is not related specifically to their unique skills and expertise should be assigned to other members of the care team.
To optimize your care team’s efforts, your clinic first must look at the types of services it provides, then decide which providers to deploy, and how the work should be divided.
Your non-practitioner staff can reduce the demand for physicians by completing tasks or procedures that do not require that level of expertise or training. These could include, for example:
The specific number of nurse practitioners, physicians, nurses, assistant technicians, and clerks will vary from clinic to clinic, and that determines how the work is shared among the team. In particular, the staff mix determines the extent and type of work that can be driven away from nurse practitioners and physicians to really maximize the capacity of the clinic.
While you might be tempted to set an arbitrary care team mix and then fit the demand to that supply, your care team composition should be determined by how each of your clinics decides to balance its supply and demand. This approach begins with demand and adjusts supply to meet the demand, within the limits of your clinic’s resources.
In dividing your clinic responsibilities, all staff members should work to the highest level of their expertise and ability and drive administrative work off their plate where possible. This concept applies to all mid-level providers, nurses, other staff members, and physicians.
One way to optimize your staff’s abilities is to establish standard protocols for regularly reoccurring conditions and processes. For example, a standard process for flu and pneumococcal vaccinations with administration by a nurse or other appropriate provider will create greater capacity for other patients within your physicians’ schedules.
Often individual nurses and other clinic staff are responsible for multiple processes, including triaging patient phone requests, managing the flow of patients through your clinic, and providing medical records and other paperwork required for the patient’s visit. Clinic systems might be improved when the work for each of these tasks is clearly assigned to certain individuals. This way, there is less opportunity for delays to build up within each separate process.
Within a system, multiple stages are required to reach the desired end service or product. Often these stages run at different times and speeds from one another, resulting in downtime while waiting for the completion of one stage to commence another.
For example, in a clinic there are stages within the system that involve the patient appointment, the provider’s presence, and the patient’s medical history, chart, and other information that triggered the appointment. Synchronizing the system and eliminating downtimes will increase its’ ability to support increased supply.
First you must identify the synchronization point, which is likely when the provider enters the exam room. To the patient, this is the most important part of the clinic visit, where the knowledge and expertise of your provider is best applied. Once identified, all stages of the system can now focus on the synchronization point, rather than on each stage individually.
a) Start the First AM and PM Appointment on Time
All your staff and providers must agree on the definition of “appointment time”. This could mean seeing the registration desk at the designated time or when the provider walks into the exam room at the designated time. Using this definition, all tasks can then be synchronized around that point to reduce wait times.
b) Complete Patient Registration by Phone When Confirming the Appointment
Obtain patient history, records and other relevant information prior to the appointment to remove steps on the day of the appointment and allow for advance planning of any needs or resources that might be required to meet the patient’s needs.
c) Use Health Prompts to Anticipate the Full Potential of Need Today
Preventive medicine guidelines might be used to generate information for the care providers on the day of the appointment. For example, a patient may be due for a flu shot or HbA1c test for diabetes which can be combined with the purpose for their existing appointment. For example, a patient may be due for a flu shot or HbA1c test for diabetes which can be combined with the purpose for their existing appointment.
d) Ensure Rooming Criteria Includes Having the Patient Ready
Rooming criteria check sheets help ensure that an exam room is ready for the provider. They should also include items to ensure that the patient is prepped for the appointment, like removing the patient’s shoes before an appointment regarding their diabetes.
Proper planning of your resources allows your staff to dedicate time to arranging specific equipment or tests needed prior to or at the time of an appointment.
Staff should review the clinic schedule ahead of time on any given week or day to better prepare for patient needs to ensure they move smoothly through the clinic process.
To better prepare your staff to anticipate or plan for contingencies, implement the use of huddles with your care team. At a predetermined time each day, the care team gathers to look at the coming schedule and anticipate the needs of the patients coming in.
Quick huddles throughout the day, as well as visual displays of information, are effective ways to remain proactive in managing supply and demand, through adjustments in the schedule, coordination of emerging patient needs, or reassignment of staff responsibilities.
Clinics can also increase supply by fully utilizing rooms and equipment, which will increase the number of patients that can be seen each day.
Open rooming means that any provider can use any exam room. In some clinics, exam rooms are specifically assigned to a clinician. For example, a clinic with 16 exam rooms might have eight providers and assign each provider to two rooms. On days when only five providers are taking appointments, only ten of the available 16 rooms would be in use because the rooms are matched to the specific providers. To maximize resources, all 16 rooms could be used on the day when only five providers are in the clinic, increasing the flexibility of the clinic to rotate patients into available rooms to keep the flow moving.
To use open rooming effectively, the layout, supplies and equipment in each exam room must be standardized so that no matter which exam room a provider uses, they know everything is there and in the same place. When there is a need for specific equipment or supplies, such as in certain specialty clinics, mobile equipment or special supply trays can be brought into the room as needed.
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.
In case you missed the first two parts in this series see the links below.
