The Institute of Medicine (IOM) report Crossing the Quality Chasm (2001a) identified six fundamental aims for health care—that it be safe, effective, patient-centered, efficient, equitable, and timely. Of these fundamental aims, timeliness is in some ways the least well studied and understood. How can timely care be ensured in various health care settings, and what are some of the reasons that care is sometimes not timely?
The report presented here was developed by the IOM Committee on Optimizing Scheduling in Health Care to answer such questions. Although the study was prompted by attention to a high-profile crisis in a health center operated by the Veterans Health Administration of the Department of Veterans Affairs (VA/VHA), and it was commissioned by the VA, the report focuses broadly on the experiences and opportunities throughout the nation related to the scheduling of and access to health care. As a “fast track” Academy study, the report is limited as to the detail of practice considerations. It reviews what is currently known and experienced with respect to health care access, scheduling, and wait times nationally, and it offers preliminary observations about emerging best practices and promising strategies. The report concludes that opportunities exist to implement those practices and strategies (including virtually immediate engagement) and presents recommendations for needed approaches, policies, and leadership.
STUDY CHARGE AND APPROACH
Convened at the request of the VA/VHA, the committee was charged with the following tasks: (1) review the literature assessing the issues, pat-
Patient- and Family-Centered Care
Patient- and family-centered care is designed, with patient involvement, to ensure timely, convenient, well-coordinated engagement of a person’s health and health care needs, preferences, and values; it includes explicit and partnered determination of patient goals and care options; and it requires ongoing assessment of the care match with patient goals.
terns, standards, challenges, and strategies for scheduling timely health care appointments; (2) characterize the variability in need profiles and the implications for the timing in scheduling protocols; (3) identify organizations with particular experience and expertise in demonstrating best practices for optimizing the timeliness of scheduling matched to patient need and avoiding unnecessary delays in delivery of needed health care; (4) consider mandates and guidance from relevant legislative processes, review wait time proposals from the VA/VHA Leading Access and Scheduling Initiative, and evaluate all evidence indicated above, along with input and comment from others in the field; (5) organize a public workshop of experts from relevant sectors to inform the committee on the evidence of best practices, their experience with acuity-specifics standards, and the issues to be considered in applying the standards in various health care settings; and (6) issue findings, conclusions, and recommendations for development, testing, and implementation of standards, and the continuous improvement of their application. Throughout its work, the committee has been guided by its view that health care must always be patient- and family-centered and implemented as a goal-oriented partnership (see Box S-1).
LEARNING FROM OTHER SECTORS
To address scheduling issues, the committee considered a number of established conceptual models and systems-based engineering approaches that have been applied in settings beyond health care. These approaches have enabled many organizations to improve quality, efficiency, safety, and customer experience. However, the success of these methods depends on their application simultaneously in every part of an interconnected system rather than being applied piecemeal to distinct individual processes, departments, or service lines. The notion of an integrated approach is a core concept for timely delivery of health care.
Systems strategies in health care delivery involve the use of scientific insights to illuminate the interdependencies of processes and elements and the effects of these interdependencies on health outcomes. The strategies also entail modeling system relationships, exploring design or policy changes, and optimizing overall performance to produce better health care delivery at lower cost and minimum waste. Most importantly, systems strategies emphasize the integration of all the systems and subsystems that influence health and the optimization of them as a whole. A systems approach to health care involves orienting the system on the needs and perspectives of the patient and family. It emphasizes an understanding of the system’s supply and demand elements, developing a capacity for data analysis and measurement strategies, and incorporating evolving technologies. Finally, it relates to creating a culture of service excellence that empowers those on the front lines to experiment, identify limitations, and learn from trials.
LEARNING FROM EXPERIENCE AND BEST PRACTICES
Drawing not only on their expertise, but also on an extensive review of the literature, the comments at a public workshop held for open discussion of experiences and strategies, and an IOM discussion paper authored by leaders of five health care organizations that have implemented transformative changes, the committee identified innovative systems models that have been shown in limited settings to improve scheduling and wait time outcomes and to have either neutral or positive effects on the quality of care and patient experience. The examples presented reflect experiences in multiple specialties, care delivery settings, and business models and in organizations of various sizes and located in various geographical regions. They draw on process reengineering, resource reallocation, and behavioral change strategies. Applicable to ambulatory practices, hospitals, and rehabilitation facilities, such system-wide improvements can increase the likelihood that the right care will be delivered at the right time to every patient. Additionally, 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.
Specific approaches that have been successful in ambulatory care settings include scheduling strategy models and options that reframe supply and demand. Scheduling models include the advanced access model, also known as open access or same-day scheduling, in which a sizeable share of the day’s appointments are reserved for patients desiring a same-day appointment (Murray and Berwick, 2003), and the smoothing flow scheduling model, which uses the operations management technique of smoothing flow to identify and quantify the types of variability in patient flow (demand) and the resources available to different patient groups (supply) (Litvak and
Fineberg, 2013). Options that reframe supply and demand include team-based workforce optimization strategies that increase provider capacity by assigning care tasks to appropriate members of the care team, delegating certain tasks to non-clinician team members (e.g., Brandenburg et al., 2015), and technology-based alternatives to in-person visits that address patient needs via phone, telemedicine, and/or mobile health units (Charles, 2000; IOM, 2000; Naylor and Imison, 2010).
Specific approaches that have been successful in inpatient and emergency care settings include the smoothing flow scheduling model, coordinated care models, and the use of systems and simulation models. Care coordination interventions can improve patient flow through hospitals by both improving output flow (i.e., assuring timely discharge) and preventing readmissions (Coleman et al., 2004, 2006). Systems models and techniques, such as Lean processes, can be used to identify and continuously monitor process inefficiencies causing the imbalances in patient demand and hospital capacity that lead to delays in patient flow and increased wait times (e.g., Cima et al., 2011; Lee et al., 2015). Simulation models can also be used as a planning tool to match hospital capacity to patient need (Everett, 2002; Jones and Evans, 2008; Kolker, 2008).
The committee presents case examples of organizations that have applied these systems strategies to improve scheduling and reduce wait times (see Chapter 4). The cases reflect experiences in multiple specialties, care delivery settings, and business models and in organizations of various sizes and geographical regions.
FINDINGS, BASIC ACCESS PRINCIPLES, AND RECOMMENDATIONS
Based on its review and discussions, the committee developed a set of findings and recommendations, which are presented throughout the report and described in detail in Chapter 5. The findings are summarized in Box S-2.
Additionally, throughout its work, the committee identified a number of commonalities among exemplary practices reflected in the literature and throughout the selected set of promising case examples. These commonalities, presented in Box S-3, represent a set of basic health care access principles for primary, specialty, and hospital and post-acute care scheduling, and also provide targets for expanded research and evaluation.
The committee recommendations, which are summarized in Box S-4, call out the need for leadership at both the national level and the level of each health care facility. Nationally, the committee emphasizes several key needs: the spread and implementation of the identified access principles; direct senior federal official collaborative leadership; tools and strategies
Summary of Committee Findings
- Variability: Timeliness in providing access to health care varies widely.
- Consequences: 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.
- Contributors: Delays in access to health care have multiple causes, including mismatched supply and demand, a 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: Although not common practice, immediate engagement for patients is achievable through queue streamlining and related systems strategies to access and scheduling.
- Supply and demand: Continuous assessment, monitoring, and realigning of supply and demand are basic requirements for improving health care access.
- Reframing: Alternatives to in-office physician visits, including the use of non-physician clinicians and technology-mediated consultations, can often meet patient needs.
- Standards: Standardized measures and benchmarks for timely access to health care are needed for reliable assessment and improvement of health care scheduling.
- Evidence: Available evidence is very limited on which to provide setting-specific guidance on care timeliness.
- Best practices: Emerging best practices have improved health care access and scheduling in various locations and serve as promising bases for research, validation, and implementation.
- Leadership: 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.
Basic Access Principles for All Settings
- Supply–demand matching through formal ongoing evaluation.
- Immediate engagement and exploration of need at time of inquiry.
- Patient preference on timing and nature of care invited at inquiry.
- Need-tailored care with reliable, acceptable alternatives to clinician visit.
- Surge contingencies in place to ensure timely accommodation of needs.
- Continuous assessment of changing circumstances in each care setting.
Summary of Committee Recommendations
For National Leadership leading to:
- Basic access principles spread and implemented.
- Federal implementation initiatives with multiple department collaboration.
- Systems strategies broadly promoted in health care.
- Standards development proposed, tested, and applied.
- Professional societies leading application of systems approaches.
- Public and private payers providing financial incentives and other tools.
For Health Care Facility Leadership leading to:
- Front-line scheduling practices anchored in the basic access principles.
- Governance commitment to leadership on basic access principles.
- Patient and family participation in designing and leading change.
- Continuous assessment and adjustment at every care site.
developed to aid adoption of systems approaches to care scheduling and delivery; and coordinated efforts among key stakeholders to build the evidence base, test best practices, develop and implement standards, and create incentives for their application. In addition, leadership is necessary to ensure that in each health care setting, practices are anchored in the basic access principles; governance at the executive and board level is fully committed; and the perspectives of patients, families, and other stakeholder groups are included in planning, implementing, and evaluating institutional approaches to scheduling.