Same-day appointments catching on with doctors

Physicians say patient satisfaction goes up and no-shows go down, but the transition to an "open access" scheduling system isn't always easy.

By Julie A. Jacob, amednews staff. Jan. 29, 2001.

Imagine this: A patient calls his or her doctor's office for an appointment. The receptionist tells the patient there's an appointment available for 1 p.m. -- today.

That scenario isn't just wishful thinking. In a dramatic shift from booking patient appointments weeks in advance, some physician practices are switching to an "open access" scheduling system in which patients can be seen on the same day that they call for an appointment.

Making the switch

Patients love it because they can get in when they actually are sick.

Physicians say they like it, too, because patients are happier, their productivity has increased, their daily patient load has dropped and revenue has remained stable or has even increased.

Kaiser Permanente pioneered the open access system, also called advance access, a few years ago in northern California. It was developed by Mark Murray, MD, who formerly headed the Kaiser Permanente Sacramento Medical Center's family practice department.

When Kaiser began analyzing its operating procedures in the mid-1990s, it became clear that Kaiser patients hated having to schedule appointments months in advance, said Dr. Murray. Yet nothing that his staff had tried in an effort to whittle down that waiting time -- adding doctors, blocking out time for walk-in appointments, centralizing appointment scheduling -- seemed to help much.

Dr. Murray finally determined that because the waiting time for appointments stayed consistently at two months, "we were roughly matching supply and demand," said Dr. Murray. "But we were two months late."

The solution, he concluded, was to drop advance scheduling, erase the distinction between urgent and nonurgent visits and simply "do today's work today."

"It's a system built around who the patient's doctor is, not on how sick the patient is," said Dr. Murray, who took a leave of absence from Kaiser two years ago to do consulting work on open access scheduling with his business partner, Catherine Tantau, RN. He has consulted with the Institute for Healthcare Improvement in Boston and the Institute for Clinical Systems Improvement in Bloomington, Minn.

Other medical groups that have adopted open access scheduling include Fairview Red Wing Health Services in Red Wing, Minn.; one practice site at the Kelsey-Seybold Clinic in Houston; Dean Medical Center in Madison; and River Falls Medical Clinic in River Falls, Wis.

The system works like this: Patients who call for an appointment are offered one that day. If they cannot make an appointment that day, they are scheduled for the next day. All appointments are scheduled in universal 15- or 20-minute blocks on the assumption that the longer and shorter appointments will balance out.

If the patient's doctor is on vacation that day, the patient is told to call back when the physician returns. If the patient needs to see a doctor urgently, he or she is scheduled with another doctor on that day. Patients who need routine follow-up are told to call the day that they are due for the follow-up appointment.

The transition period can be rough, doctors say, because they have to work extra hours to clear backlogged appointments off the books while simultaneously adjusting to practicing without an appointment book filled weeks in advance.

"Initially there was a lot of skepticism," said Kevin Rossi, MD, chief of family practice at Kaiser Permanente's Bellflower Medical Center in Bellflower, Calif. "It does take a leap of faith to move in this direction. It is a change in what they were doing."

At the Kelsey-Seybold Clinic, the biggest hurdle for doctors was adjusting to the fact that they no longer knew what types of patient appointments they would have each day, said Gerald Isaac, MD, managing physician at a Kelsey-Seybold clinic in suburban Pasadena, Texas.

"Booking everyone on the same day they called was not as scary as not defining [in advance] what patients are coming in for that day," said Dr. Isaac.

Bumpy ride smoothes out

But once the bumpy transition period is over, most doctors like the system, say physicians and administrators. At Fairview Red Wing, which switched to open access last May, doctors like the fact that they are more likely to see their own patients because their patients aren't getting frustrated with long waits for appointments, said Alison Page, the group's vice president.

In addition, productivity has gone up, added Page. "We are generating a greater relative value unit per appointment. Doctors are packing more into each appointment."

At the 16-physician River Falls Clinic, revenue has remained stable since the clinic switched to open access last fall, said the clinic's administrator, Jim Miller. The noticeable change, he said, is that physicians are seeing a higher proportion of their own patients and are spending more time with those patients.

At Kelsey-Seybold, canceled and no-show appointments have dropped significantly, said Dr. Miller. "It really has improved our efficiency."

That's also true at Kaiser Permanente, said Rossi.

However, open access scheduling isn't a panacea for every situation, doctors note. At Kaiser Permanente, for instance, doctors who see a lot of elderly patients are having trouble making the switch to a same-day appointment system.

"Elderly patients don't want to wait until that day to make an appointment ... you can't plug this into every practice and make it work," said Dr. Rossi.

Open access scheduling also requires careful monitoring of the number of patients who call each day to make sure that the number of physicians consistently matches patient demand, said Dr. Rossi.

Health care consultant Kevin Sullivan of Sullivan/Luallin in San Diego agreed that it's not a universal solution for every problem that a medical practice faces. "It addresses one issue, patient access. There are many other issues that need to be addressed in coming years."

ADDITIONAL INFORMATION:

Making the switch

The medical group staff measures each physician's number of patients and the number of patients seen each day by going through records for the past two years.
The medical group then estimates how many patients are likely to call each doctor on a given day.
Physicians work an extra hour or so each day during the four- to six-month transition period to clear out the backlog of scheduled appointments while also seeing urgent same-day appointments. Patients who call to schedule appointments in advance are told to call back on the day they need a routine or follow-up appointment.
Once the medical group switches to same-day appointments, patients are booked into universal 15- or 20-minute appointment blocks. If the patient's physician is out of the office, the patient is told to call back when the physician returns. If the patient needs urgent care, another doctor or physician extender sees that patient.
The open access system requires careful monitoring of the number of patients who call each day to make sure that supply and demand balance out.
An open access system may not work as well for groups of patients who like to schedule appointments in advance, such as the elderly.