Transforming Health Care Scheduling and Access: Getting to Now (2015)

5

Getting to Now

CAPTURING THE MOMENT

As chronicled in the committee’s assessment, access and wait time challenges exist for patients and families—as well as for providers—throughout the nation. On the other hand, the committee has found ample potential for positive and far-reaching improvements. The term “Getting to Now” reflects the committee’s determination—based on their expertise, models found within other sectors, and the literature and case examples found within health care—that there is currently an opportunity to develop systems-based approaches to scheduling and access that provide immediate engagement of a patient’s concern at the point of initial contact. These approaches include use of in-person appointments as well as alternatives like team-based care, electronic or telephone consultations, telehealth, and surge capacity agreements with other caregivers and facilities. To reach the goal of immediate engagement, given the complexity of the health care system and the interdependence of participants and processes, no single stakeholder alone can bring about the changes needed to improve access.

In the face of both the increasing complexity of diseases and interventions and the need for greater efficiency and effectiveness, the roles of health care providers have been changing rapidly, from the traditional model of autonomous practice to the current ideal of collaborative, team-based care. This is a significant change and requires the development of an entirely new mental model, particularly for physicians, who may have little experience or training in team-based care. The application of a systems perspective is

a similarly novel concept for practice cultures that have been substantially bounded by their own siloed cultures.

The committee has found that the problems resulting from access and wait time issues go beyond the costs imposed on patients by prolonged wait times, delays in the provision of care, and geographic limitations. These access challenges also generate significant costs associated with the poor quality and waste caused by delays and decreased access. Despite the extent of the challenges, this is an issue that has received little attention, is not routinely measured and reported, and is under-studied. Existing standards for appropriate wait times to get an appointment are few, are based on little evidence, and amount essentially to little more than general reference points.

Still, experiences in various places indicate that the potential exists for progress through process, service, and workforce redesign that need not be resource intensive. Although areas of excellence are steadily becoming more common—including many such areas found in the Department of Veterans Affairs (VA) and the Veterans Health Administration (VHA)—best practices are not yet broadly disseminated, and there has been limited uptake of proven tools and techniques. The collective use of systems strategies, new management approaches, and improved involvement of patients and families can move the current system forward to one that is more patient-centered and can help to provide convenient, efficient, and excellent health care in a variety of settings, without the need for costly investment. As part of the redesign process, decision makers must make creative use of the full range of factors that help to smooth demand and improve supply, including digital technologies, social media, telemedicine, and other new avenues of care delivery. Continuous personal, organizational, and national learning should be the driving forces for improved access, simplified scheduling, and decreased wait times for the nation.

The issues considered by the committee are emblematic of broader challenges and opportunities in health care: e.g., the need to orient all processes and decisions to the perspectives of patients, the importance of taking a systems perspective in dealing with the interplay of complex processes, and the requirements of executive-level leadership to affect change. Each of these challenges is important within the access and scheduling domain. Because change will require broad leadership from stakeholders throughout the nation, the findings and recommendations that follow are targeted to national and health care delivery leaders. With this report, the committee seeks to present both a vision and a roadmap for national progress in this vital area.

COMMITTEE FINDINGS

Throughout this report are various findings related to systemic problems the committee has observed, promising practices it has identified, basic premises for implementation, and the foundations and capacities required for progress (see Box 5-1). The committee’s specific findings are presented below.

Variation in Timeliness of Care

Finding: Timeliness in providing access to health care varies widely. Variation ranges from same day in some circumstances to several months in others. This is the product of generally unstructured and nonsystematic

approaches to the design, implementation, and assessment of scheduling protocols.

Consequences of Delays in Access to Care

Finding: Delays in access to health care have multiple consequences, including negative effects on health outcomes, patient satisfaction with care, health care utilization, and organizational reputation. These consequences are experienced throughout the U.S. health care system, impact how care is delivered and experienced by patients, and could be substantially diminished.

Causes of Delays in Access to Care

Finding: Delays in access to health care have multiple causes, including mismatched supply and demand, the current provider-focused approach to scheduling, outmoded workforce and care supply models, priority-based queues, care complexity, reimbursement complexity, financial barriers, and geographic barriers.

Systems Strategies

Finding: Although not common practice, immediate engagement for patients is achievable through queue streamlining and related systems strategies to access and scheduling. Contrary to the notion that same-day service is not achievable in most sites, same-day options have been successfully employed through a variety of strategies, when devoted to supply and demand assessments, working through backlogs, and achieving balance in the resource allocations and flow patterns.

Supply and Demand Assessment

Finding: Continuous assessment, monitoring, and realigning of supply and demand are basic requirements for improving health care access. Full accounting of capacity elements, scrupulously monitoring the volume and nature of demand, process redesign aimed at improving patient flow and clinic workflow, and better matching patient needs with available staff skills and duties can improve patient volume and access, decrease the cost of care, and lessen the need to add personnel.

Reframing and Expanding Alternate Supply Options

Finding: Alternatives to in-office physician visits, including the use of non-physician clinicians and technology-mediated consultations, can often meet

patient needs. Reframing the supply and demand options is possible also through electronic consultations, telehealth, and surge capacity agreements with other caregivers and facilities.

Lack of Standards for Timely Access to Care

Finding: Standardized measures and benchmarks for timely access to health care are needed for reliable assessment and improvement of health care scheduling. Standards are needed to provide reliable information on comparative performance across various care settings, practices, and circumstances with respect to patient and family experience, including care match with patient goals; scheduling practices, patterns, and wait times; cycle times; the provision of and performance experience regarding alternative care models; and effective care continuity.

Inadequate Evidence

Finding: Available evidence is very limited on which to provide setting-specific guidance on care timeliness. Reliable performance standards cannot be established without better data. To develop the evidence base, health care organizations will need reliable information, tools, and assistance from various national organizations with the requisite expertise—as well as inter-organization coordination to ensure the harmony of reporting instruments and reference resources.

Best Practices for Timely Access to Care

Finding: Emerging best practices have improved health care access and scheduling in various locations and could serve as promising bases for research, validation, and implementation. Although there is not enough available evidence to establish specific standards for scheduling and wait times, innovative systems models and case studies can be identified on the basis of empirical observations of successful practices. With further research into their efficacy, these models have the potential to be adopted more widely and to become the foundation for standards of care.

Leadership

Finding: Leadership at every level of the health care delivery system is essential to steward and sustain cultural and operational changes needed to reduce wait times. Leadership must be devoted to reflecting, sustaining, and enhancing patient-centered care in scheduling and access and the results

must be continually gathered, assessed, made available, and deployed in order to drive and reward improvement.

COMMITTEE RECOMMENDATIONS

Based on these findings, the committee offers 10 recommendations that it believes will accelerate progress toward the spirit and the practice of the immediate responsiveness envisioned as health care’s goal (see Box 5-2). The committee recommendations are aimed at the widespread adoption of the basic access principles described in Chapter 4 and summarized in Box 5-3: supply matched to projected demand, immediate engagement, patient preference, care tailored to need, surge contingencies, and continuous assessment.

The recommendations that follow are aimed at building the essential foundational elements for the implementation of these basic access principles at the national level and on through to the levels of the individual health care facility. The embedded centerpiece of the recommendations is a focus on the needs of the patient and family, and the development of the skills and tools necessary to lead an organizational culture of service excellence in the execution of that focus.

Recommendations for National Leadership

The committee recommends that

1. National initiatives to address scheduling and access issues related to primary, specialty, hospital, and post-acute care appointments should be anchored in spreading and implementing basic access principles, including: supply matched to projected demand, immediate engagement, patient preference, care tailored to need, surge contingencies, and continuous assessment.
   
   
   1. The Secretary of Health and Human Services, in close collaboration with the Secretaries of Defense and Veterans Affairs, should develop and test strategies to move from the office visit as the default site of care delivery to a broader care system, with expanded roles for telehealth, in-home visits, and group visits.
   2. The Agency for Healthcare Research and Quality should strengthen its efforts to identify and disseminate the experiences of organizations with effective, innovative activities to expedite patient access.
   3. The Office of the National Coordinator for Health Information Technology (ONC) should develop and test models of information technology to support the monitoring and analysis of operational data, including access metrics on scheduling and wait times. These data should integrate seamlessly into existing systems and be interoperable to enable communication and data
2. With active support and leadership led by the Secretaries of the Department of Health and Human Services, the Department of Veterans Affairs, and the Department of Defense, coordinated federal initiatives should be initiated to draw upon the leadership and resources of the multiple federal agencies that are important to the practical and reliable realization of access principles throughout the nation. These efforts more specifically include

4. exchange with other health care organizations and the assessment of comparative performance. ONC should also develop and test analytic tools that can continuously monitor current operational conditions, including the scheduling measures of supply and demand. ONC should provide technical assistance to health care organizations regarding the implementation of these operational data systems and analytic tools.

5. Major federally operated direct clinical service providers, including the Department of Defense and the Department of Veterans Affairs, should work individually and cooperatively to develop and test emerging best practices across different settings and geographic locations. The principles of the most successful models should be widely implemented.
6. The Health Resources and Services Administration should strengthen the capacity of its network of community health centers to share information about successes and failures in efforts to transform access to care, and it should assist with the implementation of the recommendations by partnering with professional organizations to offer education of the health care workforce.

1. All coordinated efforts across federal agencies should include representation from leaders of health care delivery systems, patients and families, and industrial engineering who should work collaboratively with leadership of the federal departments to improve the broad application, assessment, and promotion of systems strategies for continuous learning and improvement in health and health care.
   1. Capacity assessments (supply)—Assessment should be conducted on staffing levels, exam room capacity, and hours and days of operation.
   2. Patient factor assessments (demand)—Research should be conducted on the various implications of patient numbers, patient query volume, patient timing preferences, and impacts of no-shows.
2. Measure developers and accreditors such as the National Quality Forum, the National Committee for Quality Assurance, The Joint Commission, and the Leapfrog Group should collaborate in research and development initiatives to build understanding and action for proposing, testing, and applying standards related to the access principles. These initiatives should include

3. Pilot demonstrations—Alternative approaches should be tested through pilot demonstrations.
4. Systems tools and expertise—Assessment instruments should be developed for use by organizations in identifying and applying systems-oriented practices and professionals.
5. Best practice assessment—Inventories should be developed and assessed on best practices under different circumstances.

5. Professional societies should work with standards and certification organizations to advance professional awareness, understanding, and application of systems approaches, tools, and incentives for the implementation/uptake of systems strategies to assess and improve health care scheduling and access that are grounded in the six access principles. This includes
6. 1. Engineering partnership models—Models should be developed for partnering with systems engineering professionals for care improvement.
   2. Systems curricular components—Curriculum initiatives should develop modules for incorporating systems approaches into the education of health professionals.
   3. Care access research and demonstration—A research agenda should be developed for demonstration projects to improve insights on the necessary education, skill sets, and cultures that are most conducive to advancing systems approaches to care access.

6. Public and private payers—and employers who pay for care—should be active participants in system improvement through initiatives that encourage creativity and innovation in the implementation and achievement of the access principles. These initiatives include
7. 1. Payment that is consistent with or supportive of innovative approaches—Payment strategies should be developed to enable innovative access improvement approaches, such as the use of teams, virtual consults, and expanded hours.
   2. Access assurance networks—Support strategies should be developed to encourage access assurance networks, such as inter-organization backup and redundancy plans.
   3. Access learning networks—Approaches should be developed to ensure more rapid information sharing concerning successful strategies for access improvement.

Recommendations for Health Care Delivery Systems Leadership

The committee recommends that

7. The front-line scheduling practices of primary, specialty, hospital, and post-acute care appointments should be anchored in basic access principles, including supply matched to projected demand, immediate engagement, patient preference, care tailored to need, surge contingencies, and continuous assessment.
   
   
8. The leadership and governing bodies at each level of the health care delivery sites should demonstrate commitment to implementing the basic access principles through visible and sustained direction, workflow and workforce adjustment, the continuous monitoring and reframing of supply and demand, the effective use of technology throughout care delivery, and the conduct of pilot improvement efforts.
   
   
9. Decisions involving designing and leading access assessment and reform should be informed by the participation of patients and their families. The potential ways that patients could provide their expertise through informal or formal channels (e.g., patient and family advisory councils, surveys, and focus groups) include contributing input on their expectations, experiences, and preferences for scheduling practices and wait times; helping representatives of health systems explore alternative access strategies; contributing to the design of pilot improvement efforts; helping to shape communication strategies; and interfacing with governance and leadership.
   
   
10. Care delivery sites should continuously assess and adjust the match between the demand for services and the organizational tools, personnel, and overall capacity available to meet the demand, including the use of alternate supply options such as alternate clinicians, telemedicine consults, patient portals, and Web-based information services and protocols.

ACCELERATING PROGRESS

Focus on Patient and Family

Achieving meaningful improvement in scheduling and access will depend directly on how engaged patients are in the improvement process. Understanding the demand side of the scheduling equation requires a

thorough evaluation of patients’ needs and expectations for their care as well as a continuous monitoring of patients’ ability to access the care they need. No matter whether one approaches the area from the perspective of the philosophy of the care process, the effectiveness of the clinical outcome, the satisfaction of both patients and clinicians, or the development of patient-controlled health care tools, it is clear that, to an ever-increasing degree, patients have a critical and very active role to play in health care. This role is not limited to their own care but extends to participation in shaping the progress of the nation’s health system toward improved quality, efficiency, and access at every stage. Harnessing the engagement and the potential of patient and family leadership for improvements in scheduling and access can be a critical step down the path of the broader culture change that will lead to health care that is more effective and more efficient.

Systems-Oriented Strategies

The committee’s exploration of successful case studies and strategies for success revealed a strong potential—and need—for learning from the practices of other sectors in which operations research and systems strategies have transformed overall performance. There is certainly much to be gained through the use of systems strategies in reducing wait times and ensuring adequate and timely access to care while improving the effectiveness and the efficiency of the health care organization. Tools such as Lean and the lessons learned from such industries as aviation and customer service have demonstrated the significant potential that exists in the health care system for gains in efficiency and access. The success in some places of applying queuing theory and engineering models to deal with the complexity inherent in health care scheduling—the diversity of populations served, the range of services provided, and the frequency of no-shows and other anomalies—offers but one example of the importance of a system-wide perspective across all aspects of health care in embedding engineering practices, tools, and skills as a fundamental component of health care that continuously learns and improves.

Leadership

Ultimately, the successful implementation of the committee’s recommendations—and of broader efforts to transform performance in health care—will depend on leadership. This certainly means leadership from the top of the organization, at the level of the chief executive officer and board of directors, but it also means leadership involvement from stakeholders in every aspect of health care. Achieving meaningful access will require not only strategic vision at the outset but also sustained attention, assessment,

feedback, and initiative at every level of the organization. The basics of a culture of service excellence, with the full involvement of patients and families, commitment to continuous monitoring and assessment, transparency, accountability, and empowering organizational leadership and decision making from participants at every level, will help ensure that every patient—whether they are seeking help immediately or at a later point—receives the right care at the time they need and expect it.