Simplified Patient Scheduling

Preface

Simplified Patient Scheduling (SPS) is a bridge between the traditional patient scheduling system most ambulatory clinics now use (regardless of the software applied to the task), and the most sophisticated patient scheduling system: patient centered scheduling, also known as advanced access and open access.

The idea behind redesigning the scheduling system is to make it much easier for patients to get appointments when they want them, even if that means same day appointments. While this redesign delights patients, it yields additional benefits for staff as well: Much lower no-show rates, higher continuity of care (therefore faster clinical decision-making and higher quality of care), higher productivity, and less clinic chaos.

SPS is not a substitute for same day scheduling, but rather, a kind of “open access with training wheels.” SPS prepares you for the advent of a same day patient scheduling system so the transition is far easier than jumping from the traditional system to the new one “cold-turkey”.

Almost everyone readily agrees the traditional system is deeply flawed, but it is a more difficult proposition to understand why. In short, this system is based on the unstated premise that the patient schedule is “the best way to manipulate clinical workload.” Consequently, managers advocate double booking and shorter appointment slots while clinic staff members fervently hope for “no-shows” to balance the daily work load and advocate for a complex array of appointment slot types—each with its own frequency and time allocation. The bottom line: The scheduling system was never designed to make it easy for patients to access health care.

The common characteristics of the traditional system are:

  • Many visits types, each with its own rate of frequency and time allocation. If the patient calls to schedule a Pap smear, and “Pap smear” is a visit type, then the scheduler will give the patient the first open “Pap smear” appointment even if it’s a month away and despite there being other open slots available sooner. But those open slots will be allocated to other visit types. This element builds in a great degree of inflexibility for both patients and schedulers.
  • The patient schedule is manipulated by just about everyone to either increase or decrease clinician workload. Schedulers get caught in the crossfire.
  • Same day appointments are not readily available.
  • Indiscriminate double or triple booking guarantees some bad patient experiences. You have a lot of no-shows, so you make up for it by booking multiple patients into a single slot. Traditional systems do this “indiscriminately,” meaning you can book two patients with perfect “show” records in the same slot, thus guaranteeing a long cycle time for one of them.
  • Double booking would be a reasonable strategy if each patient’s “show” record was a known quantity and patients were double booked based on their probability of keeping the appointment. If two patients are booked for the same slot and one of them always shows and one never shows, then on average you have a 100% chance of a patient showing up. If into another slot you book two patients, each of whom has a 50% chance of showing, you have a 25% chance both patients will show, a 25% chance neither patient will show, and a 50% chance one of the two booked patients will show. Not an unreasonable strategy. But who among us “knows”, never mind “uses”, show rates for individual patients in booking future appointments? So, double booking without this data is asking for cycle time trouble.
  • Because of all the above, the patient scheduling system is aggravating to staff and complex to use.
  • And most importantly, it simply doesn’t work for the patient.
Caveats

You probably recognize the above traits in your own scheduling system. You may even be ready to admit it doesn’t work well for either patients or staff. So, why are there so many clinics still using the traditional method?

First, there must be a viable alternative with which staff has some familiarity. There are actually viable alternative systems and abundant evidence that the alternative systems work and work well. Second, messing around with the patient scheduling system often results in messing around with clinicians’ work schedules and workloads. This is territory where even “angels fear to tread.”

Almost always the current staffing schedule is the product of staff preferences rather than the consequence of a thoughtful, deliberate strategy of matching capacity to demand. In other words, over time, most staff gravitate to work schedules that work well for them individually. So, they are touchy about even a hint of change in this arrangement. Introduce the idea of redesigning the patient schedule system, and the typical reaction is panic, hostility, shock, resistance, and anger.

Now with the prior point in mind, consider this: Almost any initial change in the scheduling system makes matters worse rather than better in the short term. Is it clear now why more clinics do not redesign their patient scheduling systems?

Simplified Patient Scheduling

Simplified Patient Scheduling (SPS) is utilized by many Patient Visit Redesign teams during the course of testing their redesign model during test clinics (Rapid Redesign Tests or RRTs). Incorporated this way—in the context of RRTs—it is a much less intrusive way to introduce and test a patient scheduling redesign. Most redesign teams report difficulties achieving a sufficient flow of patients into their Rapid Redesign Tests. The traditional system does a great job at keeping patients at bay. This is a good time for a Redesign Team to seize the patient schedule for test clinics. And, when you seize it, redesign it.

SPS, when applied to patient visit test clinics, keeps you out of the business of assessing individual clinician work schedules, and, therefore, away from harm. Keep it simple and keep it peaceful during the redesign testing period. You will need to enlist the cooperation of at least some schedulers, and you may have to go to a paper-based scheduling template for your test clinics if, for some reason, your computerized system cannot accommodate SPS for the tests.

Here are the key elements of Simplified Patient Scheduling:

  • Reduce all visit types to one visit type called “patient visit”. Catchy, isn’t it? There are no slots called “physicals” or “immunizations” or anything else other than “patient visit”.
  • With only one slot type you need only one—hold onto your hats now—time interval for all slots: 15 minutes, for example. Yes, every slot is only 15 minutes long. “Well, hold your horsies”, you might say, “a physical is going to take me a lot longer than a follow-up visit to make sure a rash has disappeared.” Yes, that’s true. We won’t even argue that point. But both patients will be in 15 minute slots. One may take 25 minutes, and the other 5 minutes. Simply stated, there is no mathematical correlation between the times traditionally assigned to particular visits and the times spent by a clinician with a patient. An anticipated short visit can turn into a train-wreck, and an anticipated long visit can emerge in reality as a simpler and shorter encounter. Also, you can’t predict with certainty where the no-shows will occur. Allocating 30 minutes to an encounter only to have a no-show is a tremendous waste of clinician knowledge and talent.
  • Once you decide to have only a single appointment-slot type, what should the time allotment be? 15 minutes? 20 minutes? 30 minutes? The answer: The time should be very close to your average amount of time the clinician spends with a patient. In most primary care practices, this turns out to be somewhere between 13-15 minutes. If that’s the case for you, then 15 minute slots will work well. If your average is close to 20 minutes, then you may want to begin Simplified Patient Scheduling with 20 minute slots. If your average is 8-10 minutes, then 10 minute slots may be good for your initial attempt at Simplified Patient Scheduling.
  • Now create patient scheduling templates, electronic or paper-based, for a few test clinics based on one visit type and one length of visit.
  • Is that all there is to Simplified Patient Scheduling? No. The above steps establish the framework. Within any framework are tactics that yield the best results. Our framework gives us a whole clinic session divided into 15 minute slots. (Let’s use that time allocation for this example). Now divide that session into hour segments—four appointments to each hour segment. Within any hour segment, and its four appointment block of slots, you want to do the following:
    • Use the first appointment of each hour to book a patient visit that “will most likely result in a greater than 15 minute encounter.” “Geesh”, you’re saying, “I thought there wasn’t a long encounter type!” Well, there isn’t, but you still want to plan for visits that you think probably will take more time so you don’t pack them all in the same hour. Book these for the first appointment in each hour, if at all possible. This means you start each hour with a tough case, but the Patient Care Team has an hour to dig itself out of this little hole.
    • Leave one of the three remaining appointments open until the day of clinic. It doesn’t matter too much if this is the second, third, or final appointment within the hour block, and it does not have to be the same slot in every block. Fill these slots with same day appointment callers or walk-ins. Depending on your early AM walk-in population, you may wish to fill the first hour’s open slot with someone who called late the day before).
    • Two slots of every hour block are filled with “routine appointments”, or “routine patients.”
    • No slot is double-booked. That’s right. No deliberate engineering of long cycle times, poor patient satisfaction, or high staff stress in Simplified Patient Scheduling.
    • Ensure that the scheduled patients show up and show up on time for their visit. Make a thoughtful, timely and personal reminder call to them.
    • That’s it. It sounds scary, but try Simplified Patient Scheduling as described. Modify it only after trying it for at least two test clinics so you don’t modify the method based on the results of only a single experience.
Patient Centered Scheduling Systems

Simplified Patient Scheduling will show you that a redesigned patient scheduling system can really boost performance results and delight patients. Simplified Patient Scheduling is a stripped-down system that performs far better than the traditional system, but it’s insufficiently complex to accommodate demand fluctuations across days, seasons, or the varying practice styles of providers.

Advanced Access patient scheduling, also known as Patient Centered Scheduling or Open Access is a method that choreographs demand and supply. Advanced Access, like Simplified Patient Scheduling, recognizes that the traditional method blocks patient access, inhibits productivity, produces lots of walk-ins and a high no-show rate for patients with appointments. Advanced Access is based on the valid premise that patients are most likely to keep appointments if they are scheduled for when they want to come in.

Advanced Access is also based on the concept of “same day scheduling” since most patients who call for appointments prefer to come in on the same day. When this aspect of Advanced Access is well implemented, it is possible to even eliminate the triage function. Same day appointments can greatly enhance the probability that a patient can see her regular provider—thus lending itself to good continuity of care, if the clinic has mainly full-time providers.

The final piece of the foundation of this methodology is the concept of patient panel: That a definable set of patients is cared for by a Patient Care Team. This is a complex discussion and we won’t go into it here, but suffice it to say that you can’t have continuity of care without patient care panels, and you can’t have the best quality medical care without continuity.

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